Prescribing of long-acting reversible contraception (LARC) in primary care rose after introduction of the new QOF contraception indicators in 2009, a study has shown.

Quarterly prescribing (PACT) data were used from a random sample of 581 general practices in England from April 2007 to March 2012.

This sample was compared with national general practice data with respect to: the registered 15-44 year old female population, mix of urban and rural practices, deprivation, number of female GPs and ethnicity. With the exception of ethnicity (national average of White British 80% compared with 71% in the sample), there were no significant differences between the sample and the general population.

Contraceptive prescribing data were grouped into LARC (IUD, IUS, implants and injectables) and non-LARC (combined oral contraceptives (COC), progestogen only pills (POP), diaphragms and caps).

The primary outcome measure was the rate of GP-prescribed LARC per 1,000 registered women aged 15-44.

A negative binomial interrupted time-series method was used to describe the trends in prescribing of LARC before and after implementation of the QOF indicators, see table 1.

The LARC prescribing rate appeared to be stable before April 2009 with a slightly decreasing gradient of - 0.4% annually. After the introduction of the QOF indicators the LARC prescribing rate increased by 4% annually, adjusted rate ratio (RR) 1.04 (95% CI:1.03-1.06). The mean number of LARC prescriptions increased by 10% in the four years after the QOF indicators were introduced.

Of the LARC methods, prescribing for contraceptive implants increased by 88%, IUS by 27%, injectables and IUD both by 8%. COC prescribing remained the same with a 2% decreasing trend before and after the QOF whereas POP rate increased by 12% then decreased by 3% afterwards.

GPs in urban practices were less likely to prescribe LARC than those in rural practices; the difference was 27%, RR 0.77 (95% CI:0.66-0.91).

Having a female GP in the practice was associated with a doubling of the rate of LARC prescribing compared with practices without a woman GP, RR 2.03 (95% CI:1.82-2.27); this was significant for IUDs and implants, RR 2.26 (95% CI:1.76-2.90) and RR 2.40 (95% CI:1.95-2.97) respectively.

The authors concluded that the 4% annual increase in LARC prescription rates would be equivalent to 8,700 more women being prescribed LARC after the implementation of the QOF incentives. This was also accompanied by a reduction in oral contraceptive pill prescribing suggesting there could be a switch from this to a longer lasting method during the post-QOF period.

If this effect were extrapolated to the nationally registered population of women aged between 15 and 44 years, this is equivalent to an additional 110,000 women being prescribed LARC.

QOF indicators for 2014/15 have been published and GPs now only need to offer LARC advice to women issued emergency hormonal contraception.

New arrangements for local authorities in England to commission providers for LARC services are in place; this may involve current providers such as GPs and community contraceptive clinics but other qualified providers can also bid for the same services.

Both these factors may reduce the willingness of GPs to refer or provide LARC.

New training pathways agreed between the Faculty of Sexual and Reproductive Healthcare and Royal College of General Practitioners might make it more accessible for GPs to gain the expertise to fit the IUD/IUS and implants and therefore potentially increase the capacity for LARC in the community.

It remains to be seen what the impact of these new policies are on LARC prescriptions, their use and impact on unplanned pregnancies.

We need to continue our efforts to provide high quality, safe, reliable, effective contraception that is accessible and acceptable to women of any reproductive age.

Dr Richard Ma