Buckinghamshire Sexual Health Services Needs Assessment
Buckinghamshire Sexual Health Needs Assessment
Report July 2015
Version: 16.0
Ref No: P647
Date: July 2015
Authors: Dr Torquil Pyper BSc PhD Dr Cecilia Pyper MBBS MFPH Tasmin Harrison BSc Sarah Seager BSc
Commissioner: Angie Blackmore
PHAST Report - Version 16 1 Project Title & Location
Draft Report
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Version: 01
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Buckinghamshire Sexual Health Services Needs Assessment
Document Details
Date of Issue: July 2015 Version: 16.0
Project description: This report has been prepared by the Public Health Action Support Team (PHAST).
Commissioner Lead Contact Details
Name: Angie Blackmore
Role: Public Health Principal/Sexual Health Commissioner Buckinghamshire County Council County Hall, Walton Street, Aylesbury HP20 1UA [email protected] Telephone: 01296 387472
PHAST Project Lead Contact Details
Name Dr Cecilia Pyper Role: Project Lead
Email: [email protected]
Telephone: 01865 327270
Mobile: 07802753880
PHAST Project Office Contact Details
Name: Dr Catherine Brogan
Role: PHAST Executive Lead
Address: Public Health Action Support Team CIC Westlington Farm Dinton Bucks HP17 8UL
Email: [email protected]
Telephone: 020 3479 5250
Mobile: 07970 622 604
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Table of Contents 1 Executive Summary ...... 7 1.1 Overview ...... 7 1.2 Summary Recommendations ...... 8 1.3 Conclusion ...... 12 2 Buckinghamshire Sexual Health Needs Assessment 2015 ...... 13 2.1 Introduction ...... 13 2.2 Background ...... 13 2.3 Commissioning Responsibilities of Sexual Health and HIV services ...... 14 3 Buckinghamshire Demographics ...... 15 3.1 Population Profile of Buckinghamshire ...... 16 3.2 Buckinghamshire Ethnicity ...... 19 3.3 Buckinghamshire Deprivation ...... 21 4 Buckinghamshire Sexual Health Services ...... 23 4.1 Buckinghamshire County Council ...... 23 4.2 Buckinghamshire Healthcare NHS Trust ...... 23 4.3 Terrence Higgins Trust (THT) ...... 24 4.4 Community Pharmacies in Buckinghamshire ...... 26 4.5 GP Practices ...... 26 4.6 Activity of Buckinghamshire Sexual Health Services ...... 27 5 Buckinghamshire Sexual Health Profile ...... 31 5.1 Public Health England - Sexual and Reproductive Health Profile (2015) ...... 31 6 Buckinghamshire’s Sexual and Reproductive Health ...... 33 6.1 All new STIs ...... 34 6.2 Chlamydia ...... 37 6.3 Gonorrhoea ...... 40 6.4 Syphilis ...... 41 6.5 Genital warts ...... 42 6.6 Genital herpes ...... 43 6.7 HIV ...... 44 6.8 Conception ...... 53 6.9 Abortion ...... 57 6.10 Contraception ...... 61 7 Domestic Violence, Sexual Relation Violence & Child Sexual Exploitation (CSE) ...... 69 7.2 Other Sexual and Reproductive Health Indicators ...... 72 7.3 Summary ...... 83 8 The Sexual and Reproductive Health Profile of Local Authorities in Buckinghamshire ...... 86
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9 Mystery Shopper ...... 91 9.1 Context ...... 91 9.2 Mystery Shopper Results ...... 91 9.3 Mystery Shopper Discussion ...... 93 10 Key Stakeholder Interview Results ...... 94 10.1 Introduction ...... 94 10.2 Sexual Health Team ...... 94 10.3 Communication ...... 94 10.4 Access ...... 96 10.5 Sexual Health Promotion and Prevention Services ...... 97 10.6 Children and Young People ...... 97 10.7 Hard to Reach Groups ...... 98 10.8 HIV Social Care ...... 98 10.9 Training ...... 99 10.10 Future Commissioning ...... 99 10.11 Key Recommendations from the Stakeholder Interviews ...... 99 11 Bucks Sexual Health Staff Survey 2015 – Summary...... 101 11.1 Distribution ...... 101 11.2 Number of staff working from each Sexual Health Site ...... 101 11.3 Sexual Health Staff Survey Results ...... 101 12 Summary Bucks Sexual Health Public Survey 2015 ...... 105 12.1 Distribution Strategy ...... 105 12.2 Summary Results Bucks Sexual Health Services Public Survey 2015 ...... 105 13 BHT User Satisfaction Survey – Summary Results ...... 107 13.1 Buckinghamshire Healthcare NHS Trust 2013/14 ...... 107 13.2 Results Annual Patient Satisfaction Survey ...... 107 14 THT User Satisfaction Survey - Summary Results ...... 109 14.1 Summary Results from Terrence Higgins Trust (THT) Level 2 Service ...... 109 15 Key Findings and Recommendations ...... 111 15.1 Buckinghamshire Sexual Health Services ...... 111 15.2 Buckinghamshire Demographics ...... 112 15.3 Buckinghamshire Sexual Health Profile 2015 ...... 113 15.4 Summary Recommendations ...... 121 16 Conclusion ...... 125 17 Summary Evidence Review Recommendations ...... 126 17.1 Standards & Guidance ...... 126 17.2 Services Targeting Young People ...... 126 17.3 Outreach Models...... 126
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17.4 Partner Notification Activities ...... 126 17.5 Models of Closer Work with Primary Care ...... 127 17.6 Innovative New Technologies for Delivering Sexual Health ...... 127 17.7 Older People...... 129 17.8 General Trends in Sexual Health Behaviour ...... 129 17.9 Key Risk Groups ...... 129 17.10 Teenage Access to Sexual Health Services ...... 131 17.11 Victims of Violence/ Sexual Abuse ...... 131 18 Appendix 1 - Buckinghamshire Sexual Health Staff Survey 2015 ...... 133 18.1 Distribution ...... 133 18.2 Number of staff working from each Sexual Health Site ...... 133 18.3 Sexual Health Staff Survey Results ...... 133 19 Appendix 2 - Buckinghamshire Sexual Health Public Survey 2015 ...... 151 19.1 Distribution Strategy ...... 151 19.2 Results Buckinghamshire Sexual Health Services Public Survey 2015 ...... 152 20 Appendix 3 – THT Level 2 - Patient Satisfaction Survey ...... 161 20.1 Annual Patient Satisfaction Questionnaire 2014 ...... 161 21 Appendix 4- BHT User Satisfaction Survey – 2013/14 ...... 164 22 Appendix 5 - Sexual Health Services Configuration ...... 170 22.1 Local Authorities ...... 170 22.2 Primary Care ...... 170 22.3 Community Pharmacies ...... 170 22.4 Abortion ...... 171 22.5 HIV Treatment and Care & Sexual Assault Referral Centres ...... 171 23 Appendix 6 - Relevant Commissioning Standards ...... 172 23.1 Relevant National Standards for Commissioning, Organisation and Delivery of GUM Services ...... 172 23.2 Department of Health ...... 172 23.3 National Institute for Health & Care Excellence (NICE) ...... 172 23.4 British Association of Sexual Health & HIV (BASHH) ...... 173 23.5 Faculty of Sexual & Reproductive Healthcare (FSRH) ...... 174 23.6 Medical Foundation for AIDS (MEDFASH) ...... 174 23.7 Society of Sexual Health Advisors (SSHA) ...... 174 23.8 Health Protection Agency (HPA)/ Public Health England ...... 174 23.9 Public Health England (PHE) ...... 175 23.10 National AIDS Trust (NAT) ...... 175 24 Appendix 7- Key Topics Sexual Health Evidence Review ...... 176 24.1 Services Targeting Young People ...... 176 24.2 Outreach ...... 177
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24.3 Partner Notification ...... 177 24.4 Integration of Sexual Health Services with Primary Care ...... 177 24.5 Innovative New Technologies for delivering Sexual Health ...... 178 25 Appendix 8 – Evidence Review -Trends in Sexual Health Behaviour ...... 186 25.1 Trends in Sexually Transmitted Infections ...... 186 25.2 Key Risk Group: Young People (aged 15-25 years) ...... 186 25.3 Key Risk Group: People from Black African Communities ...... 187 25.4 Teenage Access to Sexual Health Services ...... 189 25.5 HIV prevention interventions that specifically target African communities ...... 190 25.6 Victims of Violence/ Sexual Abuse ...... 192 26 Appendix 9 - Evidence Review Methodology...... 194 26.1 Methodology ...... 194 27 Appendix 10 - Reducing Unintended Conceptions 2015 ...... 195 27.1 Evidence base ...... 195 27.2 How do we know it is cost effective? ...... 196 27.3 How do we know it is working? ...... 197 28 Appendix 11 - Public Health England MSM Action Plan 2015 ...... 198 28.1 Promoting the Health and Wellbeing of Gay, Bisexual and Other Men Who Have Sex with Men ... 198 29 Appendix 12 - Buckinghamshire Sexual Health Website ...... 200 30 Appendix 13 - List of Wards in Buckinghamshire ...... 201 31 Appendix 14 – Sexually Transmitted Infections ...... 204 31.1 Introduction ...... 204 31.2 Chlamydia ...... 204 31.3 Infectious Syphilis ...... 204 31.4 Gonorrhoea ...... 205 31.5 HIV ...... 205 31.6 Genital Warts ...... 205 31.7 Hepatitis C (HCV) ...... 205 31.8 Hepatitis B (HBV) ...... 205 32 Appendix 15 - Sexual Health Glossary ...... 206 33 Appendix 16 - References ...... 208
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Buckinghamshire Sexual Health Needs Assessment
1 Executive Summary 1.1 Overview This report has been prepared by the Public Health Action Support Team (PHAST) to inform Buckinghamshire County Council about the sexual health profile for the area and performance on key sexual health indicators and trend analysis it also highlights activity data for the current, Buckinghamshire Sexual Health Services. The report reviews stakeholder views both professionals and the general public and makes evidence-based recommendations to inform the sexual health commercial review and procurement process and finally, the strategic direction for sexual health and wellbeing. Commissioning evidence-based sexual health services is a challenge that requires strong leadership and strategic planning. It is important that the commissioning process takes into account the changing demographic and epidemiological profile of Buckinghamshire and the learning from past sexual health service initiatives. It is important to ensure that the future design and configuration of Integrated Sexual Health Services are developed in accordance with local needs of Buckinghamshire. The key aims of Buckinghamshire Sexual Health Services include the following: Deliver Sexual Health Services that offer high quality, rapid, accessible and appropriate sexual integrated health and reproductive sexual health care to the Buckinghamshire population. Deliver high quality prevention and screening programmes to reduce the onward transmission of STIs and HIV To optimise contraceptive use and improve access to contraceptive services Reduce the negative impacts of sexually transmitted infections including HIV on health status and on personal and social well-being Deliver a broad range of health promotion programmes that focus on prevention and wellbeing Promote sexual health and wellbeing across the life course that is focused on consensual and healthy relationships It is important that future services align with the evidence identified in this report. This report includes a series of rapid evidence reviews that offer a summary of clear and concise evidence statements based on recent and relevant evidence publications. The evidence reviews aim to provide commissioners with a robust basis for decision making and refining their future procurement. The recommendations set out in this report are derived from analyses carried out on data supplied by Buckinghamshire County Council, ONS, HSCIC, Public Health England, Buckinghamshire Health care Trust, Brook, THT and Barnardo’s R-U-Safe. The recommendations are also based on the information elicited from the corporate needs assessment which included staff user, and public surveys as well as key stakeholder interviews. The final section of this report sets out a number of Key Recommendations for commissioners. These recommendations are based on evidence derived from both the data analysis and a review of relevant literature including relevant guidance. These recommendations are intended to assist Commissioners in prioritising areas to focus on; this will ensure that future integrated sexual health services are evidence based and responsive to the needs of the local populations. This report has identified and included key guidance available from the Department of Health, the Royal Colleges, Public Health England NICE and BASHH, MEDFASH and FSRH that can be used to inform and support commissioners to design future integrated sexual health services. A good range of up-to-date standards and guidance exists (listed in the evidence review) that have important
PHAST Report - Version 16 7 Buckinghamshire Sexual Health Services Needs Assessment application in the development of all levels of services; commissioners should utilise these in their decision making. Requirements regarding exact type of service delivery are not imposed; service delivery should reflect local requirements. All levels of reproductive & sexual health services should be kept in mind when designing services. Consultant led, fully integrated services that include primary and secondary prevention and contraceptive care are recommended. Open access services, rapid access to diagnosis and treatment and promotion of outreach primary prevention to educational establishments and high-risk groups are all recommended. Evidence has identified the importance of ensuring that care pathways are fully integrated and have established high quality communication channels between the different elements of the sexual health services designed. This fact is highlighted in recent guidance published by Public Health England, Making it Work: a guide to whole system commissioning for sexual health, reproductive health and HIV (2014). This includes ensuring that prevention services as well as clinical services, and both staff and patients should be well informed about referral and communication pathways. In order to ensure that integrated sexual health service objectives and functions are most effectively implemented it is important to promote strong working relationships between clinical and health promotion services within a shared strategic framework. Core elements that should be included in a best practice integrated sexual health service model, as identified by the evidence review, include: Health promotion, prevention and community education. Partnerships with secondary care and primary care providers. High quality sexual health clinical services targeting priority populations. Partnerships with affected populations, clinicians, researchers and other relevant groups. A strong scientific research and evidence base for service, strategy, policy and planning. A strong partnership with the relevant Public Health Departments and Public Health England. Incorporation of new technologies demonstrating clinical and cost effectiveness into integrated service delivery. Accessible, clearly signposted services to joined-up pathways for sexual health needs, working with commissioners in CCGs and NHS England responsible for other sexual health services. Services delivered by well trained, informed health professionals.
1.2 Summary Recommendations Sexual and Reproductive Health Profile Indicators PHAST recommend that following Sexual and Reproductive Health Profile Indicators that are worse in Buckinghamshire than the England average values should be targeted for improvement: 1. STI testing rate (excluding Chlamydia aged < 25) / 100,000 2. STI testing positivity (excluding Chlamydia aged <25) % 3. Chlamydia detection rate / 100,000 aged 15-24 4. Chlamydia proportion aged 15-24 screened 5. HIV testing coverage, MSM (%) 6. HIV testing uptake, women (%) 7. HIV testing coverage, men (%) 8. Under 25s repeat abortions (%)
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PHAST recommend that following Sexual and Reproductive Health Profile Indicators that are ranked in the bottom 5 when compared to 12 surrounding and comparator areas should be targeted for improvement: 1. Sexual offences rate / 1,000 (PHOF indicator 1.12iii) 2. GP prescribed LARC rate / 1,000 3. HIV diagnosed prevalence rate / 1,000 aged 15-59 4. All new STI diagnoses (excluding Chlamydia aged <25) / 100,000 5. HIV testing uptake, MSM (%) 6. Under 18s conception rate / 1,000 (PHOF indicator 2.04) 7. Cervical cancer registrations rate / 100,000 8. HIV testing coverage, women (%) 9. Syphilis diagnosis rate / 100,000
PHAST recommend that following Sexual and Reproductive Health Profile Indicators that have downward converging trends towards England’s average value should be monitored closely to ensure they do not increase any further: 1. Under 18s conception rate / 1,000 (PHOF indicator 2.04) 2. Under 18s conceptions leading to abortion (%) 3. GP prescribed LARC rate / 1,000 4. Sexual offences rate / 1,000 5. Cervical cancer registrations rate / 100,000 6. Pupil absence (%)
STI Testing Buckinghamshire should increases its testing rate for STIs (in all age ranges) to match or exceed England’s average values, this will ensure that the true prevalence rate of STIs in Buckinghamshire does not go unchecked and allow a true comparison of STI diagnosis rates to be made. Buckinghamshire should increases its testing rate for Chlamydia (age 15-24) to match or exceed England’s average value, this will ensure that the true prevalence rate of Chlamydia in Buckinghamshire does not go unchecked and allow a true comparison of Chlamydia diagnosis rates to be made. HIV prevention The percentage of HIV diagnoses made at a late stage in Buckinghamshire is very close to the 50% threshold and should be monitored closely to ensure it reduces to less than 25% over the next 3-5 years. Buckinghamshire should improve HIV testing uptake and coverage for all groups but especially improve uptake for women and improve coverage for men and MSM. Under 18 conceptions Buckinghamshire should closely monitor under 18 conception rates to ensure they remain lower than the England average value. Buckinghamshire should closely monitor Under 18s conceptions leading to abortion (%) rates to ensure they remain higher than the England average value. Buckinghamshire should introduce new interventions for women under 25 having abortions to try and lower the very high rate of under 25s repeat abortions. LARC and EHC Buckinghamshire should closely monitor GP prescribed LARC rates to ensure they remain higher than the England average value. The positive or negative reasons for the decline in EHC Pharmacy consultations should be investigated further.
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C- Card The positive or negative reasons for the decline in the use of the C-Card scheme should be investigated further. Chlamydia Screening Chlamydia screening was offered to only 17% of condom clients over the 4 year period; work needs to be undertaken during 2015/16 to increase the numbers routinely offered a chlamydia test via this service. Sexual Offences The sexual offences rate in Buckinghamshire should be closely monitored to ensure it does not exceed England’s average rates. A review of sexual violence offences in Buckinghamshire should be undertaken to try to ascertain whether there is an actual increase in sexual offences in the county or whether this is a trend similar to other areas of UK where there is increased reporting of sexual offences. Site Activity The total number of attendances at sexual health services in Buckinghamshire should be monitored closely to ensure it does not follow last year’s trend and continue to decrease. Although to have a reducing number of follow-up appointments can be a positive finding; the decreasing number and percentage of follow up attendances at sexual health services in Buckinghamshire should be investigated in relation to the overall decrease in attendances. The percentage of total attendances that are follow-up varies greatly from site to site and should be investigated further. Staff Survey Ensure the STI and contraception services become fully integrated and HIV remains fully integrated. Improve communication between Level 2 and Level 3 services. Improve the record-keeping IT systems. Promote a multidisciplinary approach that includes strong links with drug and alcohol services. Promote multidisciplinary training. Improve training for primary care staff and community pharmacists. Improve and expand prevention interventions in colleges and schools. Increase out Reach services and target locations that have poor access to sexual health services. Public Survey Increase opening times especially evenings and weekends. Review location of services especially in relation to at risk and hard to reach groups. Review confidentiality procedures in relation to waiting rooms. Introduce new technologies to promote prevention messages and signposting of services. Improve primary care training to improve their delivery of sexual health services. Patient Satisfaction Survey Overall, the level of satisfaction across Buckinghamshire was considered as excellent across a number of indicators. The following indicators received lower ‘Excellent’ responses (below 90%) and could be considered for improvement: Clinic opening times (44% Excellent, 43% Good, 9% Fair, and 3% Poor). Time taken to book in at reception (68% Excellent, 29% Good, 3% Fair, 0% Poor). Level of privacy and dignity at reception (76% Excellent, 22% Good, 2% Fair, 0% Poor). Cleanliness of the waiting area (77.0% Excellent, 22% Good, 1% Fair, 0% Poor). Respect and courtesy shown by reception staff (85% Excellent, 15% Good, 0% Fair, 0% Poor). Whether the confidentiality policy was explained to you (88% Excellent, 9% Good, 2% Fair, and 0% Poor).
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Stakeholder Interviews Integrated Services A Central Organisational Hub and Spoke Model is required with clear integrated pathways. Integrate the Chlamydia Screening programme into the wider community sexual health services. Improve GP communications and integration levels-more shared updated and learning, more opportunities to link up. GPs with a Special Interest (GPwSI), especially those GPs located in the North of Bucks, to be more involved in level 2 outreach. Introduce a fast tracked referral system between community pharmacists and sexual health services. When SH services are tendered it is important that the service specification ensures that the HIV services remain integrated with other sexual health services with clear referral pathways. Introduce a central single booking system for sexual health appointments. Health promotion An awareness raising campaign is required for the public, potential and current clients and NHS staff including primary care staff. Increase the use of new technologies in sexual health prevention programs. Children and Young People Sexual health promotion for schools should be better coordinated. HIV education should be introduced from age 8 and generally be included with other illnesses e.g. cancer. NHS England HIV commissioners should collaborate with local commissioners and design improved specialist support in schools for children living with HIV; this should be coordinated with HIV health promotion and education for all children in schools to reduce HIV misconceptions about children living with HIV. Drop in clinics-that specifically offer targeted advice for young people should be available from accessible locations in Bucks every weekday. RU Safe- Recommend a “Bucks FastTrackMe” card should be introduced and given to children / young people who have been identified as vulnerable so when they make contact with the service they are fast-tracked and offered sufficient time to sort them out at one appointment rather than expecting them to return. The FastTrackMe card-could have RU Safe telephone numbers on the back. Outreach Future services need to utilise experienced sexual health outreach workers to optimise accessing the black African communities and other hard to reach at risk groups. When SH services are tendered it is important to ensure the are some HIV specialist workers who maintain the expertise regarding HIV care in the community, including benefits entitlement. Outreach prevention and health promotion services should target the MSM and sex workers in Buckinghamshire utilising new technologies. Training Staff training where possible should be integrated with shared CPD updates – to ensure all service providers get to know each other and have a shared understanding of the care pathways. Sexual Health Training and CPD should be promoted via accredited sexual health websites All sexual health staff should be aware of and where appropriate reporting to the Multi-Agency Safeguarding Hub (MASH) (based with the police). The agency is responsible for- children who are missing, SERAC (Sexual Exploitation Risk Assessment Conference), Social services, Police, sexual health, child protection, safeguarding referral, RU Safe, CAMS, Addaction, youth offending service, MARAC domestic violence support etc. Improve the skills of community pharmacists including their contraceptive knowledge.
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1.3 Conclusion Greater STI screening coverage and easier access to sexual health services is the key to improving the sexual health of Buckinghamshire’s population. Sexual health services should be geographically accessible with enough booked and walk in appointments and enough out of hours and weekend services. An integrated sexual health service should be adopted at all Hub, spoke and outreach tier levels, with a central administrative system for recording: Patient Records Patient Appointments (Booked and Cancelled) Partner Notification Site Activity Outreach Targets and Levels of Achievement Staff Administration and Training Consistent data should be collected from all sites so that new resources can be targeted at areas with high STI prevalence rates and not just areas with high diagnosis rates (that are a symptom of the introduction of a preventative intervention). Data should routinely be monitored to ensure any trends or anomalies are quickly identified. STI screening and treatment interventions should then be introduced to actively engage with populations that are at high risk of STIs. Outreach initiatives should be introduced that target hard to reach and high risk groups. Prevention and health promotion interventions should then be optimised to maintain low STI rates. The demographic groups most affected by HIV (Black African and MSM) should be targeted for preventative testing (including partner testing) and treatment. Undiagnosed and late diagnosed HIV should be recognised as major issues contributing to the spread of the disease as well as poor health outcomes. A Sexual Health Promotion Strategy should be introduced to provide sexual health information to the Buckinghamshire’s sexually active population and inform all current and future service users of what services are available and how they can be accessed. This Sexual Health Promotion Strategy should be integrated within the overall Buckinghamshire Sexual Health Strategy. The Sexual Health Promotion Strategy should use age and ability appropriate media to target all population demographic groups in Buckinghamshire. Staff from all sexual health services as well as GPs, community pharmacists and community workers should all be offered sexual health training on a regular basis to ensure they have the knowledge and skills to provide a consistently good sexual health service.
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2 Buckinghamshire Sexual Health Needs Assessment 2015 2.1 Introduction This Health Needs Assessment of Buckinghamshire Sexual Health Services has been commissioned to review current and future sexual health needs of the Buckinghamshire population and develop future potential options for commissioning services to meet those needs. The results of this health needs assessment will be used to refine the service specification sexual health commercial review and procurement process for future Buckinghamshire Sexual Health Services that will be commissioned in 2015. The aim has been to compare the sexual health indicators of Buckinghamshire Sexual Health Services with Regional Health Services performance as well as the performance of England. In addition corporate needs assessment has been carried out that has involved both staff and public surveys and key stakeholder interviews. Data has been supplied by Buckinghamshire County Council, ONS, HSCIC, Public Health England, Buckinghamshire Health Care Trust, Brook, THT and Barnardo’s R-U-Safe. The data analysis offers an overview of the prevalence of STIs in Buckinghamshire compared to other relevant areas. A series of brief evidence reviews have been conducted to inform this review. They are reported separately in section 3 and in more detail in Appendices 6-8. Key local documents that are relevant to this report include the Buckinghamshire County Council Director of Public Health’s Annual Report1, Buckinghamshire County Council Joint Strategic Needs Assessment (JSNA)2 and Buckinghamshire County Council Sexual Health Profile 20133.
2.2 Background Access to contraception is a key priority in the sexual health strategy and commissioning intentions for Buckinghamshire County Council. This report addresses the provision of services for all forms of contraception, detection and treatment of infections that are transmitted sexually (where sexual intercourse is the most common mode of transmission). Sexual health affects people’s physical and psychological wellbeing and can have an enduring impact on overall quality of life. It is a key part of an individual’s identity and includes human rights to privacy, a family life and living free from discrimination. The core elements of good sexual health are equitable relationships and sexual fulfilment with access to information and services to avoid the risk of unintended pregnancy, illness or disease. Many people with sexually transmitted infections (STIs) including HIV are unaware that they have a disease and remain undiagnosed for many years. This not only affects their overall health and wellbeing but increases the risk of transmission of the STI to other people. Unplanned pregnancies, terminations and teenage conceptions can lead to many long term emotional, health and social consequences. Sexual dysfunction can affect self-esteem leading to relationship problems. Therefore, ensuring access to appropriate sexual health information, interventions and services can have a positive effect on population health and wellbeing as well as individuals at risk. Sexual behaviour is a major determinant of sexual and reproductive health. Certain behaviours are associated with increased transmission of STI and HIV, including: Age at first sexual intercourse Number of lifetime partners Concurrent partnerships Payment for sexual services Alcohol Substance misuse
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The National Public Health Outcomes Framework (PHOF) contains three indicators specific to sexual health, highlighting the need to continue and sustain efforts in these areas: Chlamydia diagnostic rate in 15 – 24 year olds People presenting with HIV at a late stage of infection Under 18 conceptions In March 2013, a Framework for Sexual Health Improvement in England was published by the Department of Health1. This document highlighted the need for a continued focus on sexual health, across the life course and highlighted four priority areas for improvement: Sexually transmitted infections (STIs) HIV Contraception and unwanted pregnancy Preventing teenage pregnancy This needs assessment provides the latest data for Buckinghamshire for each of these priority areas and PHOF indicators, and also includes feedback from stakeholders on their assessment of current needs. 2.3 Commissioning Responsibilities of Sexual Health and HIV services Sexual health services are commissioned at a local level to meet the needs of the local population, including provision of information, advice and support on a range of issues, such as sexually transmitted infections (STIs), contraception, relationships and unplanned pregnancy. 2.3.1 Local Authorities Commission Comprehensive sexual health services including most contraceptive services and all prescribing costs, but excluding GP additionally-provided contraception Sexually transmitted infections (STI) testing and treatment, chlamydia screening and HIV testing Specialist services, including young people’s sexual health, teenage pregnancy services, outreach, HIV prevention, sexual health promotion, services in schools, college and community pharmacies
2.3.2 CCGs Commission Most abortion services Sterilisation Vasectomy Non-sexual-health elements of psychosexual health services Gynaecology including any use of contraception for non-contraceptive purposes
2.3.3 NHS England Commissions Contraception provided as an additional service under the GP contract HIV treatment and care (including drug costs for PEPSE) Promotion of opportunistic testing and treatment for STIs and patient-requested testing by GPs Sexual health elements of prison health services Sexual assault referral centres Cervical screening Specialist fetal medicine services
1 A Framework for Sexual Health Improvement in England March 2013 https://www.gov.uk/government/publications/a-framework-for- sexual-health-improvement-in-england
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Across England there is considerable regional variation in how sexual health services are provided and commissioned. They vary from distinctly separate general practice and community-based contraceptive provision with hospital-based abortion and genito-urinary medicine (GUM) services, to fully integrate sexual health services in the community. The variations occur because of differences in commissioning and contractual models used in local areas. 3 Buckinghamshire Demographics Buckinghamshire (Bucks) is a ceremonial and non-metropolitan home county in South East England. The area under the control of Buckinghamshire County Council, is divided into four districts— Aylesbury Vale, Chiltern, South Bucks and Wycombe. The Borough of Milton Keynes is a unitary authority and forms part of the county for various functions such as Lord Lieutenant but does not come under county council control. The ceremonial county, the area including Milton Keynes borough, borders Greater London (to the South East), Berkshire (to the South), Oxfordshire (to the West), Northamptonshire (to the North), Bedfordshire (to the North East) and Hertfordshire (to the East). Figure 1. Districts and population centres for Buckinghamshire and the surrounding area
Source: PHAST Mapping
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3.1 Population Profile of Buckinghamshire Buckinghamshire has a similar gender and age profile to England, except for a slightly smaller percentage of the population in the 20-34 age category that is 3.8% lower than England, (England 20.3%) (Buckinghamshire 16.5%). This age range is often associated with a higher rate of STIs and should contribute to Buckinghamshire having lower STI rates than England. The chart below shows the number of people in Buckinghamshire by sex and five year age band. The darker outline shows the profile of the England population. Figure 2. Profile of Buckinghamshire population compared to England by gender and five year age band
Source: Office National Statistics ONS, 2011 Census. The table below shows summary population numbers for Buckinghamshire and also how it is expected to grow. The growth rates are shown as annualised percentages and the projected England growth rate is showing for comparison. (ONS use a Bayesian time series forecast with their population projections.) Figure 3. Summary Population Projections for Buckinghamshire
Source: ONS, 2011 census From 2015 to 2020 the population of Buckinghamshire is set to increase from 522,596 to 543,787 (+21,191) with an annual growth rate of 0.8%. During the same timeframe the sexually active population aged 15-64 is set to increase by 4,674 with an annual growth rate of 0.29%.
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Figure 4. Buckinghamshire Population in each MSOA
Source: PHAST Map of 2014 demographic data Buckinghamshire population in each Middle-Layer Super Output Area (MSOA) ONS Census data has divided England into Output Areas (OAs) which on average have a resident population of 309 people. OAs are the smallest geographic unit for which Census data are available. Their geographical size will vary depending on the population density. OA classification has then been aggregated to classify other small area geographies, i.e. Lower-Layer Super OAs (populations of 1,000 to 3,000), Middle-Layer Super OAs (populations of 5,000 to 15,000).
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Figure 5. Buckinghamshire Population Density (population per hectare in each MSOA)
Source: PHAST Map of 2014 demographic data Population density is calculated as the population per hectare in each MSOA The population of Buckinghamshire is more concentrated to the south of the county with two large population centres in Aylesbury and High Wycombe and one smaller centre to the north in Buckingham.
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3.2 Buckinghamshire Ethnicity Figure 6. The Ethnicity of Buckinghamshire’s population by MSOA
Source: PHAST Map of 2014 demographic data Overall the ethnicity of Buckinghamshire population in 2014 is: 86% White, 9% Asian, 2% Mixed, 2% Black (African/Caribbean/British) and 0.5% Other Black.
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Figure 7. The Number of people in each MSOA from Black (African/Caribbean/British) and Other Black Groups
Number (scale)
Other Black
Source: PHAST Map of 2014 demographic data The MSOAs with the highest number of people from Black (African/Caribbean/British) and Other Black groups are located in Aylesbury and High Wycombe. In general there are a higher number of people in MSOAs to the south of the county that are from Black Ethnic groups. Apart from 2 MSOAs next to Buckingham that also have slightly higher populations.
Recommendation: Services targeting Black (African/Caribbean/British and Other Black ethnic groups need to focus on the areas outlined above
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3.3 Buckinghamshire Deprivation Figure 8. Buckinghamshire Deprivation Decile 2010
Source: Department for Communities and Local Government
Overall deprivation in Buckinghamshire is lower than average, however about 10-5% (10,300) children live in poverty. Buckinghamshire has a few small areas of relatively high deprivation located around the two main population centres of Aylesbury and High Wycombe.
Recommendation: When targeting resources and addressing access to sexual health services it is important that those areas of high deprivation receive accessible sexual health services.
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Figure 9. Health Summary for Buckinghamshire 2015
Source: Health Profiles http://fingertips.phe.org.uk/profile/health- profiles/data#gid/3007000/pat/6/ati/102/page/9/par/E12000008/are/E10000002/iid/1730/age/1/s ex/4
The Buckinghamshire 2015 Health Profile demonstrates that Buckinghamshire has: Good community indicators Good child and young person health Average adult health and lifestyle Good disease and poor health indicators (apart from hip fractures that is average) Good to average life expectancy indicators
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4 Buckinghamshire Sexual Health Services Buckinghamshire’s Sexual Health Services are targeted at the two large population centres in Aylesbury and High Wycombe where there is a higher population density. Some clinics require appointments to be made in advance whereas others are drop-in services. Current configuration of sexual health services in Buckinghamshire has been operational since 2012. Services are provided by 3 main providers as well as Levels 1 and 2 services being provided by some community pharmacies and Primary Care in Buckinghamshire. The 3 providers the following clinics and outreach services and initiatives are listed below. 4.1 Buckinghamshire County Council 4.1.1 Brook based at Wheelden House Buckingham This service is a Young People’s Clinic for people under the age of 25. The clinic is a drop-in clinic open once a week on Monday between 2:30pm and 5.00pm 4.2 Buckinghamshire Healthcare NHS Trust Buckinghamshire Healthcare NHS Trust offers Levels 1, 2 and 3 services for Specialist GUM (STI testing and treatment) and specialist contraception. 4.2.1 The Brookside Clinic The Brookside Clinic based in Aylesbury offers Level 1, 2 and Level 3 services that include the management and co-ordination of a condom C-card scheme, management of Buckinghamshire County Chlamydia Screening Programme, Emergency Hormonal Contraception, Specialist L3 Contraceptive Services, Specialist GUM (STI Testing and Treatment) Services, Young People's Clinics for people under 21 years, HIV Testing; in addition HIV treatment and care services commissioned by NHS England are provided. 4.2.2 The SHAW Clinic The SHAW Clinic based at Wycombe Hospital, High Wycombe offers Level 3 Specialist Contraceptive Services and at a separate clinic Specialist GUM (STI Testing and Treatment) Service, HIV Testing; in addition HIV treatment and care services commissioned by NHS England are provided. Both the Brookside Clinic and the SHAW Clinic offer appointments and walking and wait clinics as well as an under 21s clinic. For further details regarding the opening times please see: http://www.sexualhealthbucks.nhs.uk/provider/bht/?service_type&town&services_provided&age_group&appointments 4.2.3 Youth Enquiry Service (YES) There is also a Youth Enquiry Service (YES) available in Aylesbury that offers specialist contraceptive service to the under 25 is on Thursdays between 3.00pm- 5.00pm. This is delivered by Buckinghamshire Healthcare NHS Trust.
Out-of-Hours Opening There is one contraception clinic open at Brookside Aylesbury between 6.00- 8.00pm on a Monday. There are no STI clinics available late evenings in Aylesbury. The SHAW clinic offers two afternoon STI testing/GUM clinics on a Monday and Wednesday that are open between 1.00 pm- 7.00pm. The Shaw offers contraception clinics on Tuesday open between 5.45 pm – 7.45 pm and Thursday open between 5.45 pm – 7.30pm. There are no STI services available early mornings after 8.00pm or during weekends/bank holidays.
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4.3 Terrence Higgins Trust (THT) The Terrence Higgins Trust provides integrated contraceptive and STI testing services from a number of sites across Buckinghamshire County. 4.3.1 Wye Valley Surgery Wye Valley Surgery based in High Wycombe, Wye Valley offers integrated contraceptive and STI testing services on Mondays 2.00pm-5.00pm. Clients can make appointments or Walk-in and wait. 4.3.2 Chalfont and Gerrards Cross Hospital Chalfont and Gerrards Cross Hospital based in Chalfont St Peter offers integrated contraceptive and STI testing services on Wednesdays 6.00pm- 9.00pm. Clients must make an appointment. 4.3.3 Burnham Health Centre Burnham Health Centre based in Burnham offers integrated contraceptive and STI testing services on Tuesdays 3.00pm-6.00pm. Clients can make appointments or Walk-in and wait. 4.3.4 North End Surgery North End Surgery based in Buckingham offers integrated contraceptive and STI testing services on Tuesdays 3.00pm-6.00pm and Fridays 11.00am-2.00pm. Clients can make appointments or Walk-in and wait. 4.3.5 Aylesbury College Aylesbury College based in Aylesbury offers C-Card, Integrated Contraceptive and STI Testing Services and Young People's Clinics on Tuesdays 10.30am-1.30pm. Clients can make appointments or Walk-in and wait. 4.3.6 Amersham & Wycombe College Amersham & Wycombe College based in Amersham offers Contraception and STI Testing on Thursdays 10.30am-1.30pm. Clients can make appointments or Walk-in and wait. 4.3.7 The Bagnall Centre The Bagnall Centre based in Chesham offers integrated contraceptive and STI testing services on Thursdays 2.00pm-5.00pm. Clients can make appointments or Walk-in and wait. 4.3.8 Oasis High Wycombe and Aylesbury (HIV Service) This is a separate THT HIV Outreach and Prevention Service with 2 bases in High Wycombe and Aylesbury at the Drug and Alcohol offices of Oasis. Out-of-Hours Opening It is noticed that Terrence Higgins Trust offers one late clinic in Chalfont and Gerrards cross on Wednesday open 6.00pm- 9.00pm. Other than this clinic there are no other late evening clinics or weekend clinics offered.
Recommendation It is recommended that future service specification review the opening hours for STI/GUM and Contraception Services. Future Integrated Sexual Health Services should be available on all weekday evenings and during weekends and bank holidays.
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Figure 10. Locations of Buckinghamshire Sexual Health Services 2015
Source: PHAST Map of sexual health services listed at http://www.sexualhealthbucks.nhs.uk
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Buckinghamshire Sexual Health Services are targeted at the two large population centres in Aylesbury and High Wycombe and to the South of the county where there is a higher population density. Services are also provided in Buckinghamshire to the North. Services are well located to target the most deprived areas of the county. HIV services are located in Aylesbury and High Wycombe and are split into treatment and care services delivered by BHT commissioned by NHS England and outreach and prevention services via THT.
4.4 Community Pharmacies in Buckinghamshire Community pharmacies are a feature of most local communities, and some provide a range of prevention sexual health services, including offering chlamydia testing, participation in condom schemes and the provision of emergency contraception. The advantage of community pharmacies offering as wider range of sexual health services as possible is that they often have extended opening hours. The sexual health website lists the contact details of all community pharmacies that offer Emergency Hormonal Contraception to under 19-year-olds. For further details please see: http://www.sexualhealthbucks.nhs.uk/provider/phm/?service_type&town&services_provided&age _group&appointments
4.5 GP Practices GP Practices offer Essential (Level 1) and some Enhanced (Level 2) Sexual Health Services. The majority of the Buckinghamshire GP Practices provide basic contraceptive services under the current General Medical Services (GMS) Contract, and a minority provide primary care Medical services under the PMS (Primary Medical Services) contract. The sexual health services GP Practices provide includes providing advice about the full range of contraceptive methods available, initial advice about sexual health promotion and STIs, and referrals as necessary for specialist Sexual Health Services. Under the GMS contract all GP Practices are expected to provide prescriptions for oral contraceptives including emergency hormonal contraception and injectable contraceptives. GP Practices are also expected to provide sexual health advice and should be able to discuss all forms of contraception with a patient to be able to identify the most appropriate method for the patient and sign-post them to access this. GPs that are qualified and sign-up to the Locally Enhanced Service (LES) are also able to provide other LARC methods (Intra-Uterine and Sub-Dermal) to their registered patients. There are 53 GP practices in Buckinghamshire operating a Level 1 service with 83% signed up to deliver a LARC service under a Public Health Contract. The Public Health Team manage a database of individuals qualified to fit IUDs and IUS as well as insert implants. The competencies are monitored by an Associate Specialist in the Level 3 BHT services who delivers the training. Sexual health service provision within General Practice is variable and often dependant on the training and skills of GPs and Nurses within the practice. Approximately 75% of women go to their GP for contraception2; therefore it is essential that primary care staff receive quality sexual health training and updates to ensure high quality equitable Sexual Health Services are available across Buckinghamshire County.
2 NHS Buckinghamshire Sexual Health & HIV Strategy 2009-2014
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4.6 Activity of Buckinghamshire Sexual Health Services Figure 11. First attendances and Rebooks- All patients seen at sexual health services in Buckinghamshire
Brookside (BHT)
Source: BHT Belvan Report for all patients seen excluding HIV both FA and Rebooks). THT Blithe Lillie Report and Brook Service Activity data 2009-10 to 2014 - 15.
Overall the number of first attendances and rebooks have increased from 9,689 in 2009-10 to a peak of 12,921 in 2013-14( +33%) with a slight decrease to 12,642 in 2014-15 (-2%). The percentage of first attendances and rebooks occurring at each site in Buckinghamshire in 2014- 15 is: 47% SHAW; 36.1% Brookside; 15.6% Terrence Higgins and 1.3% Brook. From 2009-10 to 2012-13 the number of first attendances and rebooks at SHAW and Brookside increased by 13.4% and then from 2012-13 to 2014-15 decreased by -5%. Terrence Higgins Trust was commissioned from 2012-13 with robust data sets available from 2013- 14; from 2013-14 to 2014-15 the number of first attendances and rebooks has increased by 4% Brook was introduced in 2011-12 and since then the number of first attendances and rebooks has remained the same (166).
Recommendation Monitor attendances and ensure follow up appointments are in line with national standards
Figure 12. Follow up - All patients seen at sexual health services in Buckinghamshire
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Brookside (BHT)
Source: BHT Belvan Report for all patients seen excluding HIV both FA and Rebooks). THT Blithe Lillie Report and Brook Service Activity data 2009-10 to 2014 - 15
Overall the number of follow up attendances have decreased from 4,865 in 2009-10 to 3,738 in 2014-15 (-23%). The percentage of follow up attendances occurring at each site in Buckinghamshire in 2014-15 is: 52.6% SHAW; 34.5% Brookside; 10.6% Terrence Higgins and 2.4% Brook. The number of follow up attendances at SHAW have increased from 2009-10 to a peak in 2011-12 (+34%) and then from 2011-12 to 2014-15 decreased by -23%. (Overall decline of -20%) From 2009-10 to 2014-15 the number of follow up attendances at Brookside have fluctuated with a general decline of -46%. Terrence Higgins Trust was commissioned from 2012-13 with robust data sets available from 2013- 14; from 2013-14 to 2014-15 the number of follow up attendances has increased by 90%. Brook was introduced in 2011-12 and since then the number of follow up attendances has declined by 47% with a 31% reduction from 2013-14 to 2014-15.
Recommendation The decreasing number of follow up attendances should be investigated further
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Figure 13. Total - All patients seen at sexual health services in Buckinghamshire
Brookside (BHT)
Source: BHT Belvan Report for all patients seen excluding HIV both FA and Rebooks). THT Blithe Lillie Report and Brook Service Activity data 2009-10 to 2014 - 15
Overall the total number of attendances have increased from 14,554 in 2009-10 to a peak of 17,334 in 2013-14 (+19%) with a slight decrease to 16,380 in 2014-15 (-5%). The percentage of total attendances occurring at each site in Buckinghamshire in 2014-15 is: 48.3% SHAW; 35.7% Brookside; 14.5% Terrence Higgins and 1.6% Brook. The number of total attendances at SHAW have increased from 2009-10 to a peak in 2011-12 (+16%) and then from 2011-12 to 2014-15 decreased by -14%. (Overall decline of 0%) From 2009-10 to 2014-15 the number of total attendances at Brookside have fluctuated with a general decline of -11%. Terrence Higgins Trust was commissioned from 2012-13 with robust data sets available from 2013- 14; from 2013-14 to 2014-15 the number of total attendances has increased by 12%. Brook was commissioned by the former Health Authority, however the LA only has data available from 2011-12 since then the number of total attendances has declined by 23%. (This has been possible due to errors in data collection)
Recommendation The total number of attendances should be monitored closely to ensure it does not follow last year’s trend and continue to decrease.
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Figure 14. The percentage of all appointments that are follow up
Brookside (BHT)
Source: SHAW, Brookside and THT: GUMMAMM report for all patients seen (excluding HIV) from Blithe Lillie - Buckinghamshire Healthcare NHS Trust system, July 2015 – Brook: Service Manager, Brook Clinic Activity Data Overall the percentage of total attendances that are follow ups has decreased from 33% in 2009-10 to 23% in 2014-15. In 2013-14 the percentage of total attendances that are follow ups at different locations is: Brook 35%; SHAW 25%; Brookside 22% and Terrence Higgins 17%.
Recommendation Although to have a reducing number of follow-up appointments can be a positive finding; the decreasing number and percentage of follow up attendances at sexual health services in Buckinghamshire should be investigated in relation to the overall decrease in attendances. The percentage of total attendances that are follow-up varies greatly from site to site and should be investigated further. 4.6.1 Specialist Contraception Figure 15. Number of contacts for specialist contraception at Brookside Clinic in Aylesbury and SHAW in High Wycombe (BHT) Year Number of Contacts 2012/13 8270 2013/14 8405 Source: KT31 submission from Buckinghamshire Healthcare NHS Trust to HSCIC for L3 Specialist Contraception Service
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5 Buckinghamshire Sexual Health Profile 5.1 Public Health England - Sexual and Reproductive Health Profile (2015) 5.1.1 Buckinghamshire compared to England and South East Region
Figure 16. Key Sexual and Reproductive Health Indicators
Figure 17. Reproductive Health
Figure 18. Teenage Pregnancy
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Figure 19. HIV and STIs
Figure 20. Wider Determinants of Health
Source: Public health England (downloaded June 2015) http://fingertips.phe.org.uk/profile/sexualhealth/data#gid/8000058/pat/6/ati/102/page/9/par/E12 000008/are/E10000002/iid/90742/age/1/sex/4 Recommendation All Buckinghamshire indicators that are below the regional average, (especially indicators that are also below the England average) should be targeted for improvement. - HIV testing coverage, MSM (%) - Chlamydia proportion aged 15-24 screened - Chlamydia detection rate / 100,000 aged 15-24 - HIV testing uptake, women (%) - HIV testing coverage, men (%) - STI testing positivity (excluding Chlamydia aged <25) % - STI testing rate (excluding Chlamydia)
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6 Buckinghamshire’s Sexual and Reproductive Health All Public Health England - Sexual and Reproductive Health indicators are examined separately for Buckinghamshire and 12 comparator areas which are either adjacent to Buckinghamshire or have a similar population size and demographic. The graphs use the following methodology to identify the performance of Buckinghamshire in relation to the 12 comparator areas and the regional and national values: In total there are 38 sexual health indicators. Buckinghamshire values are highlighted in green The 12 comparator areas are highlighted in blue The Black line and black number are the England average value. The Red line and red number are the Thames Valley average value. The green arrow in left margin indicates the direction of a positive result for each indicator. Areas are sorted by performance with the best performing area on the left side of the graph and the worse performing area on the right. Areas with a 0 value are always displayed on the left and values with missing data on the right. Comment boxes are colour coded to show if the indicator is than England’s average value or than England’s average value Trend charts adopt the same colour coding to indicate the annual performance of Buckinghamshire. (This can be seen in the fill colour for each Buckinghamshire annual point) Source: PHE, Sexual and Reproductive Health Profiles - 2015 download http://www.phoutcomes.info/profile/sexualhealth/data#gid/8000057/pat/43/ati/101/page/0/are/E 07000154
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6.1 All new STIs Figure 21. STI testing rate (excluding Chlamydia aged < 25) / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For STI testing rate (excluding Chlamydia aged < 25) / 100,000 (2013): Buckinghamshire had a rate of 11,412/100,000 this is worse than the England average rate of 14,685/100,000 and worse than the Thames Valley average rate of 13698/100,000. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. Figure 22. STI testing rate (excluding Chlamydia aged < 25) / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For STI testing rate (excluding Chlamydia aged < 25) / 100,000: From 2012 to 2013 Buckinghamshire’s rate has remained worse than England’s average rate and worse than the Thames Valley average rate. If an area carried out no testing for STIs then the diagnosis rate for STIs would remain low, but the true prevalence rate of STIs would go unchecked and likely increase. Recommendation: Buckinghamshire should increases its testing rate for STIs (in all age ranges) to match or exceed England’s average values, this will ensure that the true prevalence rate of STIs in Buckinghamshire does not go unchecked and allow a true comparison of STI diagnosis rates to be made.
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Figure 23. All new STI diagnoses (excluding Chlamydia aged <25) / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For all new STI diagnoses (excluding Chlamydia aged <25) / 100,000 (2013): Buckinghamshire had a rate of 596/100,000 this is better than the England average rate of 832/100,000 and better than the Thames Valley average rate of 701/100,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data.
Figure 24. All new STI diagnoses (excluding Chlamydia aged <25) / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For all new STI diagnoses (excluding Chlamydia aged <25) / 100,000: From 2012 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate.
Key Result: In In Buckinghamshire the testing rate for STIs (age <25) is low compared to England’s average rate, it is therefore not surprising that the STI diagnosis rate (age <25) is also low in Buckinghamshire compared to England’s average rate. E.g. Oxfordshire has the highest STI testing rate and so unsurprisingly also has the highest STI diagnosis rate.
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Figure 25. STI testing positivity (excluding Chlamydia aged <25) (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For STI testing positivity (excluding Chlamydia aged <25) (%) (2013): Buckinghamshire had a value of 5.2% this is worse than the England average value of 5.7% but better than the Thames Valley average value of 5.1%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. Figure 26. STI testing positivity (excluding Chlamydia aged <25) %
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For STI testing positivity (excluding Chlamydia aged <25) (%): From 2012 to 2013 Buckinghamshire’s percentage has remained worse than England’s average value but better than the Thames Valley average value. The direction of a positive result is taken from PHE, but in this case it may be better to have a lower percentage of STIs testing positivity as this could be an indicator of a lower STI prevalence rate. If the same percentage of the population was tested in Buckinghamshire as was tested in England and the rate of positive results remained the same at 5.1% then the rate of STI diagnoses in under 25s would increase from 596/100,000 to 767/100,000 (+171/100,000). Note: This STI diagnosis rate is still better than the England average rate.
Key Result: Buckinghamshire should expect a 29% rise in STI diagnosis rates if it increases its STI testing rates to a similar level as England’s average rate.
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6.2 Chlamydia Chlamydia is the most common STI in Buckinghamshire, and it is most common in people under 25. Most people have no symptoms, so will not know they have it. If left untreated Chlamydia can lead to serious long-term problems and cause pain, especially in the abdomen, and may lead to ectopic (tubal) pregnancy and male and female infertility. It can also lead to arthritis in males. 6.2.1 Chlamydia Screening Programme The National Chlamydia Screening Programme (NCSP) for young people aged 15-24 commenced in Buckinghamshire in 2007. The current service is commissioned from Buckinghamshire Healthcare NHS Trust and is focused on integrating opportunistic chlamydia screening into core services i.e. general practice, community pharmacy, contraceptive and sexual health services and termination. At present there are 49 General Practitioners and 56 Community Pharmacists who offer chlamydia screening to patients. 6.2.2 Chlamydia Screening offered by Community Pharmacists in Buckinghamshire The service is for the delivery of chlamydia screening to males and females aged 15 to 24 years in community pharmacies. The chlamydia screening service ensures that all those accessing free emergency hormonal contraception or condoms, picking up contraceptive pills, seeking travel advice and/or those accessing supervised consumption and/or needle exchange in the pharmacy setting in the relevant age group are routinely offered a testing kit. The service includes: Supply of a chlamydia testing kit, including how to use the kit, where to return it and what will happen if the test is positive, plus completing the test on-site wherever possible Providing generic sexual health information, resource materials and referral to the local website – www.sexualhealthbucks.nhs.uk
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Figure 27. Chlamydia detection rate / 100,000 aged 15-24 (2013)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For chlamydia detection rate / 100,000 aged 15-24 (2013): Buckinghamshire had a rate of 1232/100,000 this is worse than the England average rate of 2016/100,000 and worse than the Thames Valley average rate of 1434/100,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data.
Figure 28. Chlamydia detection rate / 100,000 aged 15-24 (PHOF indicator 3.02)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For chlamydia detection rate / 100,000 aged 15-24: From 2012 to 2013 Buckinghamshire’s rate has remained lower than the England average rate and lower than the Thames Valley average rate
Recommendation: Buckinghamshire should increases its testing rate for Chlamydia (age 15-24) to match or exceed England’s average value, this will ensure that the true prevalence rate of Chlamydia in Buckinghamshire does not go unchecked and allow a true comparison of Chlamydia diagnosis rates to be made.
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Figure 29. Chlamydia proportion aged 15-24 screened (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For chlamydia proportion aged 15-24 screened (2013): Buckinghamshire had a value of 15.5% this is worse than the England average value of 24.9% and worse than the Thames Valley average value of 20.2%. Overall Buckinghamshire was ranked 11 out of 13 comparator areas with data. Figure 30. Chlamydia proportion aged 15-24 screened
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For chlamydia proportion aged 15-24 screened: From 2012 to 2013 Buckinghamshire’s value has remained worse than the England average value and worse than the Thames Valley average value
Buckinghamshire has a very low percentage of the population aged 15-24 that have been screened for chlamydia compared to surrounding areas and England. It is therefore not surprising that the diagnosis rate is also low. If the same percentage of the population was tested in Buckinghamshire as was tested in England and the rate of positive results remained the same, then the rate of chlamydia diagnosis in the 15-24 population would increase from 1232/100,000 to 1979/100,000. Note: This chlamydia detection rate would be similar to England’s average rate. In is important to note that chlamydia data prior to 2012 is not comparable; CTAD was introduced in 2012, prior to this GUMCAD data has been used. Key Result: Buckinghamshire should expect a 61% rise in chlamydia detection rates if it increases the percentage of the population aged 15-24 that are tested for chlamydia to a similar level as England’s average value.
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6.3 Gonorrhoea Figure 31. Gonorrhoea diagnosis rate / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For gonorrhoea diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 20.5/100,000 this is better than the England average rate of 52.9/100,000 and better than the Thames Valley average rate of 28.8/100,000. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data.
Figure 32. Gonorrhoea diagnosis rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For gonorrhoea diagnosis rate / 100,000: From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate.
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6.4 Syphilis Figure 33. Syphilis diagnosis rate / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For syphilis diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 1.8/100,000 this is better than the England average rate of 5.9/100,000 and better than the Thames Valley average rate of 2.4/100,000. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data.
Figure 34. Syphilis diagnosis rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For syphilis diagnosis rate / 100,000: From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate (except 2010 when a similar rate to Thames Valley was achieved).
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6.5 Genital warts Figure 35. Genital Warts diagnosis rate / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For genital warts diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 113/100,000 this is better than the England average rate of 133.4/100,000 and better than the Thames Valley average rate of 126.4/100,000. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data.
Figure 36. Genital warts diagnosis rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For genital warts diagnosis rate / 100,000: From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate.
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6.6 Genital herpes Figure 37. Genital Herpes diagnosis rate / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For genital herpes diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 45.7/100,000 this is better than the England average rate of 58.8/100,000 and better than the Thames Valley average rate of 52.0/100,000. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data.
Figure 38. Genital herpes diagnosis rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For genital herpes diagnosis rate / 100,000: From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate.
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6.7 HIV Figure 39. HIV diagnosed prevalence rate / 1,000 aged 15-59 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV diagnosed prevalence rate / 1,000 aged 15-59 (2013): Buckinghamshire had a rate of 1.34/1,000 this is lower than the England average rate of 2.14/1,000 and lower than the Thames Valley average rate of 1.6/1,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data.
Figure 40. HIV diagnosed prevalence rate / 1,000 aged 15-59
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For HIV diagnosed prevalence rate / 1,000 aged 15-59: From 2010 to 2013 Buckinghamshire’s rate has remained lower than England’s average rate and lower than the Thames Valley average rate.
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Figure 41. HIV late diagnosis (%) (PHOF indicator 3.04) (2011-13)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV late diagnosis (%) (PHOF indicator 3.04) (2011-13): Buckinghamshire had a value of 47.5% this is similar to the England average value of 45% and similar to the Thames Valley average value of 47.6%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data.
Figure 42. HIV late diagnosis (%) (PHOF indicator 3.04)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For HIV late diagnosis (%) (PHOF indicator 3.04): From 2009-11 to 2011-13 Buckinghamshire’s value has fluctuated at approximately 47% to 50% putting it on the border of a normal to bad result.
Recommendation The percentage of HIV diagnoses made at a late stage in Buckinghamshire is very close to the 50% threshold and should be monitored closely to ensure it reduces to less than 25% over the next 3-5 years.
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6.7.1 HIV uptake and coverage Uptake: The number of ‘Eligible new GUM Episodes’ where a HIV test was accepted as a proportion of those where a HIV test was offered. Multiple episodes of HIV test offer and uptake are included per individual within a year. ‘Eligible new GUM Episode’ is defined as a visit to a GUM clinic including all subsequent GUM attendances in the following six weeks (i.e. eligibility for testing occurs only once every six weeks). Coverage: The proportion of ‘Eligible new GUM Attendees’ in whom a HIV test was accepted. ‘Eligible new GUM Attendee’s defined as a patient attending a GUM clinic at least once during a calendar year Figure 43. HIV testing uptake, men (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV testing uptake, men (%) (2013): Buckinghamshire had a value of 85.0% this is similar to the England average value of 84.9% and similar to the Thames Valley average value of 83.8%. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data. Figure 44. HIV testing uptake, men (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For HIV testing uptake, men (%): in 2009 Buckinghamshire had a better value than England and from 2010 to 2013 Buckinghamshire’s value has remained similar to England average value.
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Figure 45. HIV testing coverage, men (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV testing coverage, men (%) (2013): Buckinghamshire had a value of 75.5% this is worse than the England average value of 77.5 % and worse than the Thames Valley average value of 77.4%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data.
Figure 46. 24. HIV testing coverage, men (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For HIV testing coverage, men (%): in 2009 and 2010 Buckinghamshire had a similar value to England but from 2011 to 2013 Buckinghamshire’s value has remained worse than England average value.
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Figure 47. HIV testing uptake, women (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV testing uptake, women (%) (2013): Buckinghamshire had a value of 73.4% this is worse than the England average value of 75.8% but better than the Thames Valley average value of 63.2%. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data. This is likely to be due to coding issues in integrated services with contraception and requires further investigation. Figure 48. 20. HIV testing uptake, women (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download HIV testing uptake for women (%): from 2009 to 2013 Buckinghamshire’s value has remained worse than England’s average value.
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Figure 49. HIV testing coverage, women (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV testing coverage, women (%) (2013): Buckinghamshire had a value of 66.9% this is better than the England average value of 65.6% and better than the Thames Valley average value of 62.8%. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data.
Figure 50. 23. HIV testing coverage, women (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download HIV testing coverage for women (%): in 2009 Buckinghamshire had a similar value to England but from 2010 to 2012 Buckinghamshire’s value was worse than England and has only got better than England’s average value in 2013. This is likely to be due to coding issues in integrated services with contraception and requires further investigation.
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Figure 51. HIV testing uptake, MSM (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV testing uptake, MSM (%) (2013): Buckinghamshire had a value of 94.7% this is similar to the England average value of 94.8% and similar to the Thames Valley average value of 94.7%. Overall Buckinghamshire was ranked 9 out of 13 comparator areas with data.
Figure 52. 19. HIV testing uptake, MSM (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For HIV testing uptake MSM (%): from 2009 to 2013 Buckinghamshire’s value has remained similar to England’s average value.
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Figure 53. HIV testing coverage, MSM (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For HIV testing coverage, MSM (%) (2013): Buckinghamshire had a value of 79% this is worse than the England average value of 86.1% and worse than the Thames Valley average value of 85.8%. Overall Buckinghamshire was ranked 12 out of 13 comparator areas with data.
Figure 54. 22. HIV testing coverage, MSM (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For HIV testing coverage, MSM (%): from 2009 to 2011 Buckinghamshire had a similar value to England but from 2012 to 2013 Buckinghamshire’s value has remained worse than England average value.
Recommendation: Buckinghamshire should improve HIV testing uptake and coverage for all groups but especially improve uptake for women and improve coverage for men and MSM.
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6.7.2 Antenatal Infectious Disease Screening – HIV The NHS Antenatal Infectious Disease Screening Programme offers all pregnant women screening for four infections: hepatitis B, HIV, syphilis and susceptibility to rubella Women with hepatitis B, HIV or syphilis are offered care and treatment to reduce the risk of passing the infection to their baby, and for their own health and wellbeing. Women who are not protected against rubella (called rubella susceptible) are offered vaccination to protect future pregnancies. This section addresses Antenatal Infectious Disease Screening for HIV. Figure 55. Antenatal infectious disease screening – HIV coverage, Buckinghamshire NHS Trust
Source: Buckinghamshire Healthcare NHS Trust 2013-2015 The antenatal infectious disease screening (HIV coverage) in Buckinghamshire has improved from Q2 of 2013/14 onwards with an achieved coverage of 99.8% to 99.9% in all quarters up to Q2 2014/2015.
Since 2004, the Health Protection Agency’s National Antenatal Infection Screening Monitoring (NAISM) Programme (now part of PHE), has centrally collated IDPS surveillance data. The data is analysed and published annually: (www.gov.uk/infectious-diseases-during- pregnancyscreening-vaccination-and-treatment). The IDPS and NAISM programmes continue to work together to improve future data quality. Hepatitis B - Uptake* 97.7% - Number of positive results* 3,982 - (0.58%) Seen by specialist within 6 weeks of identification†68.4% HIV Coverage† 98.8% - Uptake* 97.5% - Number of positive results* 1,749 (0.25%) Syphilis Uptake* 97.7% - Number of positive results* 944 - (0.14%) Rubella susceptibility - Uptake* 97.8% - Number susceptible* 44,650 (6.59%) * Data from NAISM † data from IDPS Source: 2014 NHS Screening Programmes Report http://www.screening.nhs.uk/publications
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6.8 Conception Figure 56. Under 18s conception rate / 1,000 (PHOF indicator 2.04) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For under 18s conception rate / 1,000 (PHOF indicator 2.04) (2013): Buckinghamshire had a rate of 17.2/1,000 this is better than the England average rate of 24.3/1,000 and similar to the Thames Valley average rate of 16.8 /1,000. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data.
Figure 57. Under 18s conception rate / 1,000 (PHOF indicator 2.04)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For under 18s conception rate / 1,000 (PHOF indicator 2.04): From 1998 to 2013 Buckinghamshire’s rate has remained better than England’s average rate. From 2007 to 2013 the England average rate has steadily reduced by 7% each year but in the same time frame the Buckinghamshire rate has only reduced by 4.5% each year. If this trend continues by 2021 Buckinghamshire would have a similar rate to England. Recommendation: Buckinghamshire should closely monitor under 18 conception rates to ensure they remain lower than the England average value.
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Figure 58. Under 16s conception rate / 1,000 (PHOF indicator 2.04) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For under 16s conception rate / 1,000 (PHOF indicator 2.04) (2013): Buckinghamshire had a rate of 2.0/1,000 this is better than the England average rate of 4.8/1,000 and better than the Thames Valley average rate of 2.8 /1,000. Overall Buckinghamshire was ranked 2 out of 11 comparator areas with data.
Figure 59. Under 16s conception rate / 1,000 (PHOF indicator 2.04)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For under 16s conception rate / 1,000 (PHOF indicator 2.04): From 1998 to 2013 Buckinghamshire’s rate has remained better than England’s average rate.
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Figure 60. Under 18s births rate / 1,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For under 18s births rate / 1,000 (2013): Buckinghamshire had a rate of 4.8/1,000 this is better than the England average rate of 7.8/1,000 and better than the Thames Valley average rate of 5.1 /1,000. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data.
Figure 61. Under 18s births rate / 1,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For under 18s births rate / 1,000: From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate.
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Figure 62. Under 18s conceptions leading to abortion (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For under 18s conceptions leading to abortion (%) (2013): Buckinghamshire had a value of 55.1%; this is similar to the England average value of 51.1% and similar to the Thames Valley average value of 54.8%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data.
Figure 63. 9. Under 18s conceptions leading to abortion (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For under 18s conceptions leading to abortion: From 1998 to 2012 Buckinghamshire’s value has remained higher than England’s average value, but in 2013 Buckinghamshire had a similar value to England.
Recommendation: Buckinghamshire should closely monitor Under 18 conceptions leading to abortion (%) to ensure they remain lower than the England average value to demonstrate good access to contraceptive services.
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6.9 Abortion The Department of Health has suppressed the Local Authority level data at source for Buckinghamshire. But data is available for NHS Aylesbury Vale and NHS Chiltern and using this data, the populations can be extrapolated and rates for Buckinghamshire calculated. Please note that the Buckinghamshire County Council boundary differs to that of the 2 CCGs combined. The CCGs currently commission abortion care. This needs to be taken into account when reviewing the data. PHE State that - ‘Data is provided only for upper tier local authorities…Local authority values have been suppressed where geographical boundaries differ from CCGs and differencing from the CCG values disclose small numbers. Secondary local authority values are then suppressed to prevent disclosure of small numbers by differencing from regional totals. This affects: Buckinghamshire, Oxfordshire, York and North Yorkshire.’ Figure 64. Calculation of Abortion rates for Buckinghamshire 2014
Calculated values are shown in Red and use the formula shown in the far right column Source: Abortion statistics for England 2014: https://www.gov.uk/government/collections/abortion-statistics-for-england-and-wales
Figure 65. Rate of Legal abortions per 1000 women in each age range (2014)
Note: Buckinghamshire’s rates are calculated by combining NHS Aylesbury Vale and NHS Chiltern The total number of abortions in Buckinghamshire was calculated by combining the numbers recorded in NHS Aylesbury Vale and NHS Chiltern. In 2014, there were 1,320 abortions, with 6% aged under 18, 10% aged 18-19, 28% aged 20-24, 22% aged 25-29, 17% aged 30-34 and 18% aged 35 or over. The total abortion rate / 1,000 women for Chiltern and Aylesbury Vale CCG areas is 13.9/1000, this rate is below England average rate of 16.5/1000 and is similar to Thames Valley average rate of 14.3/1000.
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Figure 66. Rate of Legal abortions per 1000 women for all ages (2014)
Note: Buckinghamshire’s rates are calculated by combining NHS Aylesbury Vale and NHS Chiltern Source: Abortion statistics for England 2014 For the rate of Legal abortions per 1000 women for all ages (2014): Buckinghamshire had a rate of 13.9/1,000 this is better than the England average rate of 16.5/1,000 and similar to the Thames Valley average rate of 14.3 /1,000. Overall Buckinghamshire was ranked 7 of 12 comparator areas with data. Figure 67. Rate of Legal abortions per 1000 women aged under 18 (2014)
Note: Buckinghamshire’s rates are calculated by combining NHS Aylesbury Vale and NHS Chiltern Source: Abortion statistics for England 2014 For the rate of Legal abortions per 1000 women aged under 18 (2014): Buckinghamshire had a rate of 8.0/1,000 this is better than the England average rate of 11.1/1,000 and similar to the Thames Valley average rate of 8.4 /1,000. Overall Buckinghamshire was ranked 3 of 8 comparator areas with data.
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6.9.1 Repeat Abortions Figure 68. Number of Legal abortions: method of abortion & repeat abortions (2014)
Figure 69. Number of Legal abortions: purchaser and gestation weeks (2014)
Source: Abortion statistics for England: 2014 https://www.gov.uk/government/collections/abortion-statistics-for-england-and-wales Buckinghamshire has a 47% Medical and 53% Surgical use of abortion methods, which is similar to England values of 50% Medical and 50% Surgical and Thames Valley values of 43% Medical and 57% Surgical. 37% of legal abortions in Buckinghamshire are repeat abortions. With 28% repeat in under 25 age group and 44% repeat in 25 and over. Similar values are achieved in England and Thames Valley. 4.5% of legal abortions in Buckinghamshire are purchased in NHS Hospitals, 92% are purchased in NHS independent sector and 3% are purchased privately. The privately funded percentage is slightly higher than the percentages achieved in England and Thames Valley.82% of legal abortions in Buckinghamshire are 3-9 weeks gestation, 9% are 10-12 weeks gestation and 9% are 13+ weeks gestation. Similar percentages are achieved in England and Thames Valley.
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Figure 70. Abortions under 10 weeks (%) (2014)
Source: Abortion statistics for England 2014 Note: Buckinghamshire’s rates are calculated by combining NHS Aylesbury and NHS Chiltern For abortions under 10 weeks (%): Buckinghamshire had a value of 82.1% this is better than the England average value of 81.1% but lower than the Thames Valley value of 84.1%. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data. Figure 71. Under 25s repeat abortions (%) (2014)
Source: Abortion statistics for England 2014 Note: Buckinghamshire’s rates are calculated by combining NHS Aylesbury Vale and NHS Chiltern For under 25s repeat abortions (%): Buckinghamshire had a value of 28.0% this is worse than the England average value of 27.0% and worse than the Thames Valley average value of 26.3%. Overall Buckinghamshire was ranked 12 out of 12 comparator areas with data.
Recommendation: Buckinghamshire should introduce new interventions for women under 25 having abortions to try and lower the very high rate of under 25s repeat abortions.
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6.10 Contraception Figure 72. GP prescribed LARC rate / 1,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For GP prescribed LARC rate / 1,000 (2013): Buckinghamshire had a rate of 53.9/1,000 this is similar to the England average rate of 52.7/1,000 but lower than the Thames Valley average rate of 56.1/1,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data. Figure 73. 7. GP prescribed LARC rate / 1,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For GP prescribed LARC rate / 1,000: From 2011 to 2012 Buckinghamshire’s rate has remained higher than England’s average rate, but in 2013 Buckinghamshire’s rate has slightly reduced and is now similar to England’s average rate.
Recommendation: Buckinghamshire should closely monitor GP prescribed LARC rates to ensure they remain higher than the England average value.
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6.10.1 Emergency Hormonal Contraception (EHC) Emergency hormonal contraception is contraception that prevents pregnancy following unprotected sex. It is available in three main forms, Levonelle (effective for up to 72 hours after unprotected sex) and Ella One, or an emergency intrauterine device (IUD), both of which can be used up to 120 hours after having unprotected sex. The main method used is Levonelle sometimes referred to as ‘the morning after pill’. In Buckinghamshire, Levonelle and Ella One can be obtained from GPs, and sexual health services. Levonelle is also available free of charge to young women under 19 years of age from community pharmacies signed up to the Public Health Contract with Bucks County Council. The scheme offers free EHC to young women under 19 years of age. Any clients that are 19 years or over should either pay for EHC at the pharmacy or be referred to an alternative service for free EHC.
Emergency Hormonal Contraception provided by Community pharmacies in Buckinghamshire Community pharmacies are at the core of provision of sexual health information and advice. It offers anonymity and a range of opening hours that are attractive for some target groups, such as young people. Safer-sex messages are crucial in improving the health of those who are sexually active and community pharmacies can contribute to maintaining the reduction in rates of unintended pregnancies and promote an increase in chlamydia diagnosis rates. Community pharmacy is able to provide Levonelle free to young women under 19 years of age when participating in the EHC public health service and incorporates: Provision of Emergency Hormonal Contraception and related advice including urgent Referral to other services if 72 hours+ but less than five days Provision of a travel card wallet containing the Buckinghamshire sexual health website Information and condoms Signposting to sexual health services for contraceptive needs and STI screening or other appropriate services Promotion of chlamydia screening and provision of testing kits.
Participating Community pharmacies The tables below show the community pharmacies in Buckinghamshire that are signed up to EHC, by district and whether the pharmacy is signed up to provide Chlamydia screening, In Buckinghamshire 44 community pharmacies (of 96) formally signed up to provide the Emergency Hormonal Contraception (EHC) service in 2014/17. Table 1: EHC community pharmacies in Chiltern and South Bucks Districts
Signed up to Signed up Number of Number of Pharmacy Chlamydia for EHC in Consultations prescriptions LES 2014/15 provided provided Amersham Health Centre, Amersham Yes Yes 4 4 Lloyds Pharmacy, High Street, Yes Yes 11 9 Beaconsfield Boots, Gerrards Cross Yes Yes 15 14 Lloyds, Iver No Yes 3 3 Prestwood Pharmacy, Prestwood Yes Yes 7 7 Total for the Chiltern and South Bucks Area 40 37 Source: Buckinghamshire County Council 2015
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Figure 74. EHC community pharmacies in Wycombe District
Signed up to Signed up Number of Number of Pharmacy Chlamydia for EHC in Consultations prescriptions LES 2014/15 provided provided Lloyds Pharmacy, Bourne End Yes Yes 4 4 Boots, High Street, High Wycombe Yes Yes 81 79 Central, High Wycombe Yes Yes 47 46 Marlow Pharmacy Yes Yes 14 14 Priory Pharmacy, High Wycombe Yes Yes 82 78 Victoria Pharmacy, High Wycombe Yes Yes 12 12 Rymead Pharmacy, High Wycombe Yes Yes 6 6 Total for the Wycombe Area 246 239 Source: Buckinghamshire County Council 2015
Figure 75. EHC community pharmacies in Aylesbury Vale District
Signed up to Signed up Number of Number of Pharmacy Chlamydia for EHC in Consultations prescription LES 2014/15 provided s provided Lloyds Pharmacy, High Street, Aylesbury Yes Yes 28 28 Tesco, Aylesbury Yes Yes 9 8 Hampden Pharmacy, Aylesbury Yes Yes 3 3 Jardines, Buckingham No Yes 10 10 Lloyds Pharmacy, Princes Risborough No Yes 5 5 Rowlands Pharmacy, Princes Risborough Yes Yes 3 3 Total for the Aylesbury Vale Area 58 57 Source: Buckinghamshire County Council
Figure 76. Total number of EHC consultations from 2008 through to 2014 is:
2008/09 673 2009/10 604 2010/11 646 2011/12 552 - Levonelle supplied at 541 consultations 2012/13 – no data available 2013/14 360 – Levonelle supplied at 358 consultations 2014/15 344 – Levonelle supplied at 333 consultations Source: Buckinghamshire County Council
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Figure 77. Number of EHC consultations, 2008/09 to 2013/14
Source: Buckinghamshire County Council 2015 (In 2012/13 there is a missing data set.) There is a downward trend in the number of EHC consultations currently taking place in community pharmacies from 673 in 2008/09 to 360 in 2013/14. Levonelle may not be supplied for a number of reasons at every consultation, for example if more than 72 hours has passed since unprotected sex, or the client does not meet the criteria of the Patient Group Direction (PGD). However, the young person should always be referred to appropriate contraceptive services to meet their ongoing needs. For 2014/2015 Levonelle was supplied at 97% of all consultations, this is in comparison to 99% for 2013/14 and 98% for 2011/12. Figure 78. EHC consultations according to age of young women Ages Number of 15 Consultations29 16 88 17 100 18 117 19 <5 20 <5 25 <5 27 <5 35 <5 Not Known <5 Grand Total 344 Source: Buckinghamshire County Council 2015 The table above indicates for <5 people age was not recorded; this has improved on the previous year in which age wasn’t recorded for 8 people. The largest proportion of people seen were 18 years of age (34.0%), this is consistent with the previous year, with a slight percentage increase of 4%. The pharmacy scheme offers free EHC to young women under 19 years of age. In 2013/14 the percentage of consultations provided to each age group was: age 15 = 8%, age 16 = 26%, age 17 = 29% and age 18 =34%. 6 people were over 18 and 4 had no age recorded.
Recommendation: The decline in EHC Pharmacy consultations should be investigated further to assess whether this is a positive or a negative trend in relation to overall services.
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6.10.2 Condom C Card Scheme Data 2011/12 to 2014/15 The C-Card scheme is aimed at young people between 13-24 years old who can register to get a range of free condoms, femidoms, lube, dams, information and advice. The aim of the service is to promote reproductive and sexual health and help young people to access local services in Buckinghamshire. Condoms are free to under 25’s and high risk groups. The scheme is intended to make condoms readily available via non-statutory sites e.g. youth centre and youth cafes, drop-in’s etc. It is managed and governance arrangements via the sexual health services at Buckinghamshire Healthcare NHS Trust. All sites signed up to the scheme have to undergo Tier 1 and Tier 2 SH training. The aim of the condom scheme is to prevent unintended pregnancies and reduce the spread of sexually transmitted infections (STI’s) including HIV, by raising awareness of good sexual health. Young people are more likely to use condoms if they are engaged in discussion, as well as shown how to use them and are more likely to use a service that is convenient, where they feel welcome and more likely to ask for advice if they don’t feel stigmatised for doing so. In a nutshell, it gives young people a chance to talk about their relationships and sexuality in a safe, non-judgemental and confidential space with an adult they can trust. The service is commissioned via Buckinghamshire Healthcare NHS Trust and specifically targets young people under the age of 25 years and/or high risk groups of poor sexual health. Young people formally sign up to the scheme, meet with a professional who provides a set number of condoms, advice on how to use them correctly and information on healthy relationships and signposts to other key services for long term contraceptive needs. The professional may be for example, a trained Youth Worker and enables young people choice, rather than go through their doctor or local sexual health service. All the workers participating in this scheme undergo two levels of training with local sexual health clinical experts.
Buckinghamshire Condom Service 2011/12 to 2014/15 (4 years) There are around 26 condom distribution sites in Buckinghamshire; they are usually distributed from non-statutory venues e.g. Health Zone drop in’s, via school nurses or youth workers etc. Nearly 4,000 under 25 year olds have accessed the condom scheme over a four year period 2011-2015 with a smaller number of older clients who are high risk e.g. drug and alcohol users During the four year period 65,790 condoms were issued The majority of the 4,000 clients over the four years were aged between 15 and 17 years. For the 4 year period 713 pregnancy tests were issued, 88 of which were positive, 625 negative. Recommendation: Chlamydia screening was offered to only 17% of condom clients over the 4 year period; work needs to be undertaken during 2015/16 to increase the numbers routinely offered a chlamydia test via this service.
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Figure 79. Gender breakdown of clients using the sexual health C-Card scheme
Source: Buckinghamshire County Council 2015 ( - There is missing data 2014/15)
There has been a gradual decline of approximately 45% in the use of the C-Card scheme from approximately 375 in 2011-2012 to 200 in 2013-2014. This may be due to poor data submissions and requires further investigation. In all quarters users of the C –Card Scheme were as follows: Approximately 50% of clients are male and 50% are female. Approximately 80% (or more) were white and 20%(or less) were BME Only a very small percentage declared they had a disability
Recommendation: The decline in the use of the C-Card scheme should be investigated further.
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Figure 80. Declaration of disability of clients using the Condom C-Card scheme 2011/12- 2014/15
Source: Buckinghamshire County Council 2015 Figure 81. Ethnic breakdown of clients using the Condom C-Card Scheme 2011/12 to 2014/15
Source: Buckinghamshire County Council 2015( - There is missing data 2014/15)
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Figure 82. Detailed ethnic breakdown of clients using the Condom C-Card scheme 2011/12- 2014/15 - Detail of all BME groups excluding White British
Figure 83. Age breakdown of clients using the Condom C-Card Scheme
Source: Buckinghamshire County Council 2015 Approximately 75% of clients are aged 14-18 The main clients using the condom scheme are aged between 15 to 17 years with a linear increase in use up to a peak of 22 years; from 22 years onwards there is an exponential decay in use of C-Cards with a minimum value achieved from age 26 onward. The small number of clients accessing the scheme in older age groups will relate to high risk groups e.g. drug and alcohol users or sex workers.
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7 Domestic Violence, Sexual Relation Violence & Child Sexual Exploitation (CSE) 7.1.1 Domestic Violence Data In total in 2013-2014 6,964 cases of Domestic Violence and Abuse (DVA) were reported to the police (TVP, 2014). It is estimated that 16,624 women and girls aged 16-59 in Buckinghamshire have been a victim in the last year (Home Office Ready Reckoner Toolkit, 2014). Working on a repeat rate of 43% (TVP latest data), this will mean for current reports 2,995 will be repeat victims of DVA with an estimated 7,148 women and girls aged 16-59 having been a repeat victim in the last year. DVA reporting continues to increase year on year and it is believed that this is due to increased awareness raising and training of professionals resulting in increased confidence to report. Source Buckinghamshire County Council Safer Communities Team Needs Assessment 2014. 7.1.2 Sexual Assault and Referral Centre (SARC) The long-term physiological and psychological effects on a victim of sexual abuse and exploitation can be profound and longstanding. Crimes of sexual abuse are often unreported or hidden by the victim for fear of repercussions or feelings of shame. Harmoni for Health provide a service at Upton Hospital and in Bletchley, dedicated to meet the needs those who have experienced rape, sexual assault or abuse, including children. B The table below shows the trend in sexual violence offences in Buckinghamshire between 2013 and 2015. The figures suggest that there is an increase in reporting of all sexual offences and all sexual offences have increased over the last two years except for sexual activity offences have decreased. Figure 84. Sexual Violence Offences in Buckinghamshire 2013/14 & 2014/15
Offence 2013/14 2014/15 All Sexual Offences 602 740 Rape 139 197 Sexual Assault 192 263 Sexual Activity 171 129 Other Sexual Offences 100 151
Source: Thames Valley Police Data 2013-2015 In Buckinghamshire from 2013/14 to 2014/15: Overall sexual offences have increased by 23% from 602 to 740 Rape has increased by 42% from 139 to 197 Sexual assault has increased by 37% from 192 to 263 Sexual activity has decreased by -25% from 171 to 129 Other sexual offences have increased by 51% from 100 to 151 – This may be due to improved reporting.
Recommendation: A review of sexual violence offences in Buckinghamshire should be undertaken to try to ascertain whether there is an actual increase in sexual offences in the county or whether this is a trend similar to other areas of UK where there is increased reporting of sexual offences.
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Figure 85. Sexual offences rate / 1,000 (PHOF indicator 1.12iii) (2013-14)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For sexual offences rate / 1,000 (PHOF indicator 1.12iii) (2013-14): Buckinghamshire had a rate of 0.99/100,000, this is similar to the England average rate of 1.01/1,000 and similar to the Thames Valley average rate of 1.0/1,000. Overall Buckinghamshire was ranked 12 out of 13 comparator areas with data.
Figure 86. Sexual offences rate / 1,000 (PHOF indicator 1.12iii)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For sexual offences rate/1,000 (PHOF indicator 1.12iii): From 2010/11 to 2012/13 the rate has remained lower than the England average rate but in 2013/14 the Buckinghamshire rate is similar to England rate. The rate for Buckinghamshire shows an increasing trend compared to England.
Recommendation: The sexual offences rate and trend in Buckinghamshire should be closely monitored to ensure it does not exceed England’s average rates.
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7.1.3 Barnardo's R-U-Safe? R-U-Safe? in Buckinghamshire works from the premise that young people under the age of 18 who are involved in sexual exploitation, are being abused. The service aims to reach out to vulnerable young people by providing a holistic package of care delivered through assertive outreach, one to one engagement and awareness raising/prevention and preventative groups/programmes. In common with a number of Barnardo’s services concerned with sexual exploitation, R-U-Safe is committed to working with some of the most vulnerable young people in Buckinghamshire. The service works with young people to promote safety, healthy relationships, reduce risky behaviour and increase self-worth and self-esteem, so as to raise their aspirations and enable them to make positive choices for the future. This includes encouraging and supporting young people to exit harmful relationships. The direct work includes but is not limited to, a range of activities, programmes and opportunities that assist in addressing their diverse and complex needs. R U Safe has a client centred approach and each young person will be assessed on their individual circumstances.
Missing Service This aspect of R-U-Safe works with young people aged between 11 and 18 who have been reported missing and returned home. Referrals are received via Thames Valley Police for young people in Buckinghamshire. People who go missing are vulnerable to sexual exploitation.
Counselling Service The service offers emotional support through their counselling service to help young people process difficult experiences, concerns and issues in a safe and supportive environment. This further increases young people confidence, resilience and ability to identify positive ways to move forward. This service is only available to those open to R U Safe according to need.
The total number of young people RU Safe worked with in Buckinghamshire during 2014-2015, was 198 (172 female and 26 male). The most common age group was 14 and 15 years old. Significantly, RU Safe also worked with 2 ten year old girls – this is the first year RU Safe has had to do this. The majority of RU Safe clients come from White British heritage, though there is some representation from Black Caribbean and Asian communities. Over the year 2014-2015, 6 of RU Safe female clients experienced pregnancy.
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7.2 Other Sexual and Reproductive Health Indicators Figure 87. Population vaccination coverage - HPV (%) (2013-14)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For population vaccination coverage - HPV (%) (2013-14): Buckinghamshire had a value of 88.4% this is better than the England average value of 86.7 and similar to the Thames Valley average value of 88.6/1,000. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data.
Figure 88. Population vaccination coverage - HPV (%) (PHOF indicator)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For population vaccination coverage - HPV (%): From 2010/11 to 2013/14 Buckinghamshire’s value has remained better than England’s average value.
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Figure 89. Pelvic inflammatory disease (PID) admissions rate / 100,000 (2013-14)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For pelvic inflammatory disease (PID) admissions rate / 100,000 (2013-14): Buckinghamshire had a rate of 134.4/100,000, this is better than the England average rate of 235.7/100,000 and better than the Thames Valley average rate of 160.1/100,000. Overall Buckinghamshire was ranked 3 out of 13 comparator areas with data.
Figure 90. Pelvic inflammatory disease (PID) admissions rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For pelvic inflammatory disease (PID) admissions rate / 100,000: From 2008/09 to 2013/14 Buckinghamshire’s value has remained better than England’s average value.
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Figure 91. Ectopic pregnancy admissions rate / 100,000 (2013-14)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For ectopic pregnancy admissions rate / 100,000 (2013-14): Buckinghamshire had a rate of 62.5/100,000, this is better than the England average rate of 86.9/100,000 and better than the Thames Valley average rate of 74.6/100,000. Overall Buckinghamshire was ranked 2 out of 13 comparator areas with data.
Figure 92. Ectopic pregnancy admissions rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For ectopic pregnancy admissions rate / 100,000: From 2008/09 to 2012/13 Buckinghamshire’s value has remained similar to England’s average value and in 2013/14 Buckinghamshire’s value was better than England’s average value.
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Figure 93. Cervical cancer registrations rate / 100,000 (2010-12)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For cervical cancer registrations rate / 100,000 (2010-12): Buckinghamshire had a rate of 7.3/100,000, this is similar to the England average rate of 9.2/100,000. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data.
Figure 94. Cervical cancer registrations rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For cervical cancer registrations rate / 100,000: in 2009/11 Buckinghamshire’s rate was better than England’s average rate but in 2010/12 Buckinghamshire’s rate was similar to England’s average rate.
Recommendation: The Cervical cancer registrations rate in Buckinghamshire should be closely monitored to ensure it does not exceed England’s average rates.
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Figure 95. Under 18s alcohol-specific hospital admissions rate / 100,000 (2010-13)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For under 18s alcohol-specific hospital admissions rate / 100,000 (2010-13): Buckinghamshire had a rate of 23.9/100,000, this is better than the England average rate of 44.9/100,000 and better than the Thames Valley average rate of 27.4/100,000. Overall Buckinghamshire was ranked 4 out of 13 comparator areas with data.
Figure 96. 12. Under 18s alcohol-specific hospital admissions rate / 100,000
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For under 18s alcohol-specific hospital admissions rate / 100,000: From 2010 to 2014 Buckinghamshire’s value has remained better than England’s average value.
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Figure 97. Percentage people living in 20% most deprived areas in England (2012)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For percentage people living in 20% most deprived areas in England (2012): Buckinghamshire had a value of 0% this is better than the England average value of 20.4% and better than the Thames Valley average value of 3.5%. Overall Buckinghamshire was ranked equal first out of 13 comparator areas with data.
Values have remained the same for England, Thames Valley and Buckinghamshire from 2012 to 2013
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Figure 98. Under 16s in poverty (%) (PHOF indicator 1.01ii) (2012)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For under 16s in poverty (%) (PHOF indicator 1.01ii) (2012): Buckinghamshire had a value of 9.7% this is better than the England average value of 19.2% and better than the Thames Valley average value of 11.6%. Overall Buckinghamshire was ranked 3 out of 13 comparator areas with data.
Figure 99. 13. Under 16s in poverty (%) (PHOF indicator 1.01ii)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For under 16s in poverty (%) (PHOF indicator 1.01ii): From 2006 to 2012 Buckinghamshire’s value has remained better than England’s average value.
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Figure 100. GCSE achieved 5A*-C including English & Maths (%) (2012-13)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For GCSE achieved 5A*-C including English & Maths (%) (2012-13): Buckinghamshire had a value of 71% this is better than the England average value of 60.8% and better than the Thames Valley average value of 66.1%. Overall Buckinghamshire was ranked 1 out of 13 comparator areas with data.
Figure 101. GCSE achieved 5A*-C including English & Maths (%)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For GCSE achieved 5A*-C including English & Maths (%) (2012-13): From 2011/12 to 2012/13 Buckinghamshire’s value has remained better than England’s average value.
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Figure 102. 16-18 year olds not in education employment or training (%) (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For 16-18 year olds not in education employment or training (%) (2013): Buckinghamshire had a value of 3.5%; this is better than the England average value of 5.3% and better than the Thames Valley average value of 4.3%. Overall Buckinghamshire was ranked 4 out of 13 comparator areas with data.
Figure 103. 14. 16-18 year olds not in education employment or training (%) (PHOF indicator 1.05)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For 16-18 year olds not in education employment or training (%): From 2011 to 2013 Buckinghamshire’s value has remained better than England’s average value.
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Figure 104. Pupil absence (%) (PHOF indicator 1.03) (2012-13)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For pupil absence (%) (PHOF indicator 1.03) (2012-13): Buckinghamshire had a value of 5.10%; this is similar to the England average value of 5.26% and similar to the Thames Valley average value of 5.01%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data.
Figure 105. Pupil absence (%) (PHOF indicator 1.03)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For pupil absence (%) (PHOF indicator 1.03): in 2009-11 Buckinghamshire’s value was better than England’s average value but in 2010-12 Buckinghamshire’s value is similar to England’s average value.
Recommendation: The pupil absence (%) in Buckinghamshire should be closely monitored to ensure it does not exceed England’s average rates.
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Figure 106. First time entrants to the youth justice system rate / 100,000 (2013)
Source: PHE, Sexual and Reproductive Health Profiles 2015 download For first time entrants to the youth justice system rate / 100,000 (2013): Buckinghamshire had a rate of 242/100,000, this is better than the England average rate of 441/100,000 and better than the Thames Valley average rate of 352/100,000. Overall Buckinghamshire was ranked 2 out of 11 comparator areas with data.
Figure 107. First time entrants to the youth justice system rate / 100,000 (PHOF indicator 1.04)
Source: PHE, Sexual and Reproductive Health Profiles - 2015 download For first time entrants to the youth justice system rate / 100,000: From 2010 to 2013 Buckinghamshire’s rate has remained better than England’s average rate.
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7.3 Summary A low diagnosis rate will not always be indicative of low prevalence rates, as the higher the percentage of the population that is tested for any STI the higher the diagnosis rate will be. All diagnosis data should therefore only be considered with close examination of test coverage and uptake in each area and in each demographic group.
Recommendation: PHAST recommend that following sexual and reproductive Health Profile indicators that are worse in Buckinghamshire than the England average values should be targeted for improvement: 1. STI testing rate (excluding Chlamydia aged < 25) / 100,000 2. STI testing positivity (excluding Chlamydia aged <25) % 3. Chlamydia detection rate / 100,000 aged 15-24 4. Chlamydia proportion aged 15-24 screened 5. HIV testing coverage, MSM (%) 6. HIV testing uptake, women (%) 7. HIV testing coverage, men (%) 8. Under 25s repeat abortions (%)
Recommendation: PHAST recommend that following sexual and reproductive Health Profile indicators that are ranked in the bottom 5 when compared to 12 surrounding and comparator areas should be targeted for improvement. 1. Sexual offences rate / 1,000 (PHOF indicator 1.12iii) 2. GP prescribed LARC rate / 1,000 3. HIV diagnosed prevalence rate / 1,000 aged 15-59 4. All new STI diagnoses (excluding Chlamydia aged <25) / 100,000 5. HIV testing uptake, MSM (%) 6. Under 18s conception rate / 1,000 (PHOF indicator 2.04) 7. Cervical cancer registrations rate / 100,000 8. HIV testing coverage, women (%) 9. Syphilis diagnosis rate / 100,000
Recommendation: PHAST recommend that following sexual and reproductive Health Profile indicators that have downward converging trends towards England’s average value should be monitored closely to ensure they do not diminish further: 1. Under 18s conception rate / 1,000 (PHOF indicator 2.04) 2. Under 18s conceptions leading to abortion (%) 3. GP prescribed LARC rate / 1,000 4. Sexual offences rate / 1,000 5. Cervical cancer registrations rate / 100,000 6. Pupil absence (%)
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Buckinghamshire Sexual Health Services Needs Assessment Figure 109. Buckinghamshire Rank compared to 12 comparator areas for each Sexual and Reproductive health indicator (Public Health England)
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8 The Sexual and Reproductive Health Profile of Local Authorities in Buckinghamshire The following tables summarise the 2013 Local Authority sexual health epidemiology reports (LASER) for all Local Authorities in Buckinghamshire and can be used to help pin point where any improvement should be targeted. The LASER report does not include L2 data and also has inaccuracies in relation to contraception data as they have only used SRHAD and BHT the larger provider submitted by KT31 in 2013/14. Figure 110. Buckinghamshire LASER Reports – STIs
Source PHE LASER Reports 2013 All 4 Districts in Buckinghamshire are ranked from middle to performing well for the rate of new STI diagnosed per 100,000 residents: Wycombe (639.3) Aylesbury Vale (499.5), South Bucks (502.7) and Chiltern (366.8) when compared to an England average rate of 810.9. Approximately 53% of STIs diagnosed are in males and 47% in females.
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Approximately 53% of STIs are diagnosed in young people aged 15-24. A lower percentage of MSM are diagnosed in Wycombe (7%) compared to other Districts (9-14%). South Bucks and Wycombe have a much higher % (12%) of new STIs diagnosed in people who were born overseas compared to other Districts (6%) Although the majority of all STIs diagnosed are in White Ethnic groups there is a much higher diagnosis rate of STIs in black ethnic groups (higher in 3 of the 4 Districts than the England average). There is a higher reinfection rate with STIs for males in South Bucks, Wycombe and Aylesbury compared to England average. There is a higher reinfection rate with STIs for females in Chiltern and South Bucks compared to England average. Figure 111. Buckinghamshire LASER Reports – STI Type
Source PHE LASER Reports 2013 The percentage of young people aged 15-24 that were tested for chlamydia is low in all Districts in Buckinghamshire compared to the England average of 24.9%, Chiltern (10.4%), Wycombe (13.6%), South Bucks (15.3%) Aylesbury Vale (19.8%). It is therefore not surprising that the chlamydia diagnosis rate in people aged 15-24 is also very low compared to England. Overall Buckinghamshire had an 8% positivity rate for young people aged 15-24 tested for chlamydia with a higher value of 10% in Wycombe.
Commissioners should be aware that diagnosis rates are not always a good indicator of prevalence rates. This is because the higher the percentage of the population that is tested, the higher the diagnosis rate will be. As all areas of Buckinghamshire have low test rates the rate of chlamydia diagnosis is correspondingly low.
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All areas of Buckinghamshire should have increase chlamydia testing in young people aged 15-25, especially in areas like Wycombe with low percentages of the young population being tested and with high positivity rates.
The rate of gonorrhoea diagnoses is much lower in all Districts in Buckinghamshire than the England average rate. The rate of syphilis diagnosis in South Bucks is the same as the England average rate of 5.9 but is much higher than the rate in other Districts. The rate of Genital Warts diagnoses is much lower in all Districts in Buckinghamshire than the England average rate. The rate of Genital Herpes diagnosis in Wycombe (58.9) is slightly higher than the England average rate (58.8). Figure 112. Buckinghamshire LASER Reports – HIV Data
Source PHE LASER Reports 2013 The HIV prevalence rate in all Districts is Buckinghamshire is lower than the England average. Wycombe has a slightly higher prevalence rate (1.6) than the other Districts. Of the adults receiving HIV care: 39% Wycombe, 36% Aylesbury Vale, 14% South Bucks and 11% Chiltern 61% Male, 39% Female, 48% White, 38% Black African, 61% Heterosexual , 31% MSM,
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Buckinghamshire (47.5%) has a slightly higher percentage of HIV diagnoses that were made at a late stage of infection than the England average (45%). Chiltern (75%) and Wycombe (53%) have a higher percentage of HIV diagnoses that were made at a late stage of infection than South Bucks (45%) and Aylesbury Vale (40%). This is especially relevant to Wycombe that has the highest rate of diagnosed HIV compared to the other Districts. South Bucks and Aylesbury Vale have lower uptake and coverage of HIV testing at eligible GUM clinics compared to England’s average. Figure 113. Buckinghamshire LASER Reports – Conception, Abortion and Contraception
Source PHE LASER Reports 2013 The under 18 conception rate of 17.2 for Buckinghamshire is much lower than the England rates of 27.7. Under 18 conception rates are lower in Chiltern (13.5%) and South Bucks(16.5) than in Wycombe (17.9) and Aylesbury Vale (19.2) South Bucks, Wycombe and Chiltern have a higher proportion of under 18 conceptions leading to abortion than other Districts (especially South Bucks (76.2%) that is ranked 9 in the UK) South Bucks as a higher rate of LARCs prescribed in primary care to women aged 15-44 than the other Districts In Buckinghamshire LARCs account for 11.8% and oral contraception 87.6% of prescribed contraceptives
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It should be noted that if high rates of gonorrhoea and syphilis in a population are seen, this reflects high levels of risky sexual behaviour. Nationally, young people aged 15-24 years, MSM and black Caribbean ethnic groups have been shown to have higher rates of new STIs. Rates are calculated using 2012 ONS population estimates * % change not provided where rate per 100,000 population in 2012 was 0.0 ** Out of 326 local authorities, 1st rank has the highest rates. Rank within England has been based on alphabetical order of local authority name where rate for local authority was 0.0 per 100,000 population. Any increase in gonorrhoea diagnoses may be due to the increased use of highly sensitive Nucleic Acid Amplification Tests (NAATs) and additional screening of extra-genital sites in MSM. Any decrease in Genital Warts diagnoses may be due to a moderately protective effect of HPV-16/18 vaccination. Any increase in Genital Herpes diagnoses may be due to the use of more sensitive NAATs. Data Source: The Genitourinary Medicine Clinic Activity Dataset v2 (GUMCAD) and chlamydia test and diagnosis data are sourced from the Chlamydia Testing Activity Dataset (CTAD).
Figure 114. The Rank out of 326 Local Authorities in England for different sexual health markers (1st rank is worst performing in this table)
Source : PHE LASER Reports 2013 Recommendation All Local Authorities receiving low ranks (worst performance) should be targeted for improvement.
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9 Mystery Shopper 9.1 Context A Mystery shopper initiative was requested by the commissioners. The Mystery shopper initiative was designed to enable the commissioners and service leads to have an independent view of client experiences of accessing sexual health services across Buckinghamshire. A single Mystery shopper was selected by the PHAST team to visit selected sites. Following careful discussion regarding confidentiality and protocol it was agreed with the PHAST team that the Mystery shopper would adhere a set format of requests that would be consistently asked at each sexual health clinic contacted. Contact was made by telephone and by visiting the selected clinics listed below. The score was allocated according to the way reception staff responded to the Mystery shopper’s request. The Mystery shopper made a series of requests that were in relation either to personal needs or in relation to the needs of a partner. If all variables listed below could not be addressed during a discussion with reception, a follow-up telephone call was carried out a few days later to ensure each topic area was addressed. The Likert score was allocated according to the responses made by the reception staff. 9.2 Mystery Shopper Results 9.2.1 Introduction The clinics for the Mystery shopper to visit were 2 clinics delivered by Buckinghamshire Healthcare NHS Trust i.e. SHAW clinic (GUM clinic) at Wycombe Hospital and Brookside Clinic in Aylesbury. Both sites operate a separate Level 3 GUM and contraceptive services. The Level 2 clinics are run by THT and operate in eight locations across the county i.e. High Wycombe, Chesham, Burnham, Chalfont & Gerrards Cross, 2 Further Education (FE) Colleges and the Swan Practice in Buckingham (2 clinics). Figure 115. Sexual Health Clinics Contacted by Mystery Shopper Site Visits BUCKS Sexual Health - HNA - MYSTERY SHOPPER (VISITS) Overview All the clinics were surprisingly varied in the environment and the services they offered. This information was obtained either by simply asking a few questions (for a friend) to the receptionist before making up an excuse and /or phoning again later to ask a particular question that had been omitted. Reception, Welcome and Greeting Quality of Treatment Ease of Access Total
Score
nd
f f
f f
nd nd
a
o
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Room Room
Times
Gender
Atmosphere
Choice Choice Available
pening a pening
Quality Quality
Takeaway
Politeness
Information
O
Waiting Time Waiting
Closing Hours Closing
Drop In Times In Drop
Bus Route Route Bus Confidentiality Chlamydia Test Chlamydia WYCOMBE HOSPITAL 5 4 4 5 4 5 1 5 4 5 42 BROOKSIDE CLINIC 5 4 5 4 5 5 5 5 4 5 47 HIGH WYCOMBE 4 5 2 4 4 5 3 4 1 1 33 CHESHAM 5 4 3 1 5 1 1 4 1 1 26 BURNHAM 4 5 4 1 5 1 5 1 1 1 28
Very Good Good OK Poor Very Poor 5 4 3 2 1
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Figure 116. Sexual Health Clinics Contacted by Mystery Shopper Telephone Requests BUCKS Sexual Health - HNA MYSTERY SHOPPER (Telephone Call) Receptionist Phone Quality Waiting Time Politeness Quality Of Information Total WYCOMBE HOSPITAL 4 4 5 13 BROOKSIDE CLINIC 4 5 5 14 HIGH WYCOMBE 3 5 4 12 CHESHAM 5 5 3 13 BURNHAM 1 5 5 11
Very Good Good OK Poor Very Poor 5 4 3 2 1 9.2.2 Sexual Health Clinic Observations by Mystery Shopper
Mystery Shopper Report - Overview All the clinics were surprisingly varied in the environment and the services they offered. I obtained this information either by simply asking a few questions (for a friend) to the receptionist before making up an excuse and or phoning again later to ask a particular question I had forgotten to request.
SHAW Clinic at Wycombe Hospital - The clinic had a very fast reception with no queue. - A choice of a male and female staff member was available. Staff were fairly neutral (non-judgemental). - Confidentially is among the best at this clinic as the waiting room is in a separate room to the reception. - Good bus routes from all around and very easy to find the clinic. - There was no choice of a takeaway chlamydia test.
Brookside Clinic, Aylesbury - There was no waiting time at this clinic. - The waiting room had the nicest atmosphere of all the clinics that I visited with a separate waiting room for the GUM clinic. - They offer takeaway chlamydia tests and offer a choice of the doctor gender e.g. male and female. - Staff were very friendly.
Wye Valley Surgery High Wycombe - The waiting time wasn’t too bad. It was among the more busy clinics that I visited. - Although the room was full of people and I’m sure some of them heard my questions about chlamydia tests, the receptionist was very confidential and explained my options in a quieter voice so that the other people in queue didn’t overhear her. - The atmosphere of the waiting room was among the worst due to the old chairs and outdated décor. - Takeaway tests were apparently provided at the pharmacy opposite the clinic. - Again there was no choice for a takeaway chlamydia test.
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Bagnell Centre Chesham - This clinic was fairly unique. The receptionist was set up in a small hall on a collapsible table and the environment was much more casual. The staff here were amongst the friendliest I met and were more than happy to give you their time. - There was no option for a male doctor but I was quickly given the details of the High Wycombe clinic which is a 30 minute bus ride away where a choice of doctor was available. - The clinic was very easy to find and had a very frequent bus route. - Again there was no choice for a takeaway chlamydia test.
Burnham Health Centre - There was no receptionist in the sexual health waiting room. However, the receptionist at the main desk was happy to talk me through the process of filling out forms and waiting for an appointment and offered me the option of a takeaway chlamydia test. Out of all the clinics I visited, this was the only clinic which offered this option. - Their process is fairly non-confidential as if you want to have an STI test you have to sit down in the waiting room with a green clipboard and forms on your lap, indicating your situation to all other patients in the room. - A choice of a female or male doctor is only available some of the time. The means of getting to and from the clinic via bus from anywhere means a 1 hour wait and a choice of one route.
9.3 Mystery Shopper Discussion Overall the Mystery shopper had a positive experience and appreciated the responsiveness of the reception staff. This Mystery Shopping exercise has highlighted some key areas where access to services needs to improve. Most of these key areas are similar to those elicited via the stakeholder interviews and surveys. Key areas to address are Waiting-room confidentiality at some of the clinics Opening times Access in relation to public transport Access via drop-in clinics Access to a clinician where preference for gender of Health Professional is important
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10 Key Stakeholder Interview Results 10.1 Introduction A series of key stakeholder interviews were conducted; some were via telephone and the remaining face-to-face interviews. Prior to the interviews the key stakeholders were invited to complete a brief semi-structured questionnaire administered via email that addressed the following key areas. Please list three strengths of the current Sexual Health Services in Buckinghamshire (this includes all specialist services e.g. STI’s, HIV, contraception, abortion, sexual assault, psychosexual, health promotion and those sexual health services provided in primary care and pharmacy e.g. LARC, chlamydia screening and provision of EHC) Please list three things you would like to see improved regarding Sexual Health Services in Buckinghamshire How would you like to see sexual health promotion change over the next five years? Do you think there is good partnership working on sexual health in Buckinghamshire across all the sexual health service providers, the local authority, general practice, community pharmacy, and NHS England commissioners? - (please circle) Yes /No - Any Comments Any other comments on sexual health services in Buckinghamshire? What is your role in supporting the Sexual Health Services Which area(s) do you work in? The Sexual Health Lead for Buckinghamshire County Council identified the key stakeholders who were invited to be interviewed; she also invited other members of staff to identify any other key stakeholders. Level 1 Services - Brook Service and GPs/Community Pharmacists from primary care Level 2 Services - Terrence Higgins Trust and HIV Outreach and Prevention Services Level 3 Services- Service Leads Key sexual health informants e.g. RU Safe and (BCC) Social Care In addition the views of individuals attending the Bucks Sexual Health Network were elicited during the meeting that was held on 13 May 2015. 10.2 Sexual Health Team Overall there were positive statements regarding the performance of the current sexual health team. It was reported that the commissioners are well informed and experienced; they understand the need of the service and are responsive to new ideas and developments. Clinical and non-clinical staff are multi skilled are able to work across sites and across the various areas of health care in sexual health and contraception. The clinical staff offer a wide range of knowledge and expertise available to draw on. The teams have good skills and of good understanding of the current care pathways. There are some concerns that some members of the clinical team need to improve their knowledge and skills with further training. Where a number is shown in brackets it indicates the number of interviewees made similar responses. 10.3 Communication
Integration (5) A central organisational hub and spoke model is required with clear pathways. There should be a united service across Buckinghamshire-health, social care and partner agencies all working together to address people’s overall wellbeing and inequalities.
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There needs to be improved communication with GPs in primary care. Concern was raised that clients are attending Level 3 service when they could attend level 2 services if asymptomatic and GPs are still referring to level 2 for cases that should go directly to level 3. Currently there are 2 separate services chlamydia is in parallel need to be in integrated into normal care Bucks, personnel are not willing to integrate – a community service that was all 3 contraception, STI and chlamydia’s
Recommendation – Fully Integrated Sexual Health Services A central organisational hub and spoke model is required with clear integrated pathways Integration of Integrate the Chlamydia Screening programme into the wider community sexual health services.
Improve interagency communications Ensure all service providers are aware about how to refer to specialist agencies such as RU Safe Improve interagency communications and interagency referral pathways between Brook, THT, drug and alcohol and RU Safe. There should be more partnership working across all providers; providers should use their knowledge and skills to refer appropriately rather than trying to cover everything, which isn’t within their own area of expertise.
Links with Other Services (4) Overall the sexual health services in Buckinghamshire are reported as working well together with good networking and liaison. There are good links between Level 2 services, GP services and with the Obstetrics and Gynaecology Department for coil removal. There are good links with third sector partners, e.g. bpas, RU Safe, Brook-counselling/support for the under 25s, drug and alcohol. Recommendation -Improved integration with primary care and utilisation of GPwSI skills Improve GP communications and integration levels-more shared updated and learning, more opportunities to link up. GPs with a Special Interest (GPwSI), especially those GPs located in the North of Bucks, to be more involved in level 2 outreach being funded via the PH Contract
The Role of Community Pharmacists in Delivering Sexual Health Care Community pharmacists could have a greater role in improving sexual health services in Buckinghamshire if they had better sexual health contraceptive knowledge. As pharmacy services are open for longer hours especially at weekends pharmacists can offer an improved access seven days a week. Communications between pharmacy and sexual health services could be improved with a fast track referral system being established from pharmacy to sexual health services. Recommendation - The role of community pharmacists in delivering sexual health care Improve the skills of community pharmacists including their contraceptive knowledge. Introduce a fast tracked referral system between community pharmacists and sexual health services
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Improved Signposting and Referral Care Pathways Clients are not aware of the different levels of service there should be better signposting and advertising of services explaining where best to go for a service with different sexual health conditions. Clients should know that they can attend their own GP for many sexual health services. Clients are still attending level 3 services when they could attend level 2 if asymptomatic. GPs are still referring to level 2 for cases that should go directly to level 3. The needs to be a clearer understanding of the role of community services in the provision of less complex sexual health and contraceptive support, so that clinical provision can be reserved for only the most complex cases, and the patient pathway is made as simple as possible. Patients should be made aware that where appropriate they should be seeking level 1 care; there needs to be more information including posters and leaflets to get this message across. Recommendation - Improved communications regarding sexual health care pathways An awareness raising campaign is required for the public, potential and current clients and NHS staff including primary care staff.
Information Technology (2) Ensure all Levels 1, 2 and 3 are using electronic records from the same system, thus saving money from duplication of services, ensuring all levels can see client test results, and ensuring the patient journey is smooth and seamless. A central single booking system to complement the Buckinghamshire sexual health website would ensure clients are seen in the most appropriate service for their needs. It was noted there is a comprehensive and user friendly sexual health website, accessible and up to date. As a recommendation to increase the use of IT resources for health promotion and reduce reliance on paper information resources Recommendation - Improve IT Systems Introduce a central single booking system for sexual health appointments Increase the use of IT in sexual health prevention programs 10.4 Access Location of Services (Two) There is a good range of available clinic and community based venues to meet the needs of local people. SHAW and Brookside clinics have very good sites and facilities.
Opening Hours of Sexual Health Services (2) There should be Saturday morning Sexual Health Clinics
Good Integrated HIV Services (Two) HIV care is co-located and integrated with sexual health and contraception across two sites. Concerns were raised regarding fragmentation of the HIV outreach and prevention and clinical specialist HIV services when services are put out to tender. Recommendation – Maintain Integration of HIV services
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It is important that when HIV services are tendered the service specification ensures that the HIV services remain integrated with other sexual health services with clear care pathways for referral. 10.5 Sexual Health Promotion and Prevention Services
Health promotion (2) There is good health promotion with innovative outreach initiatives. Increased capacity for health promotion, as currently very limited in terms of hours available. There should be improved integration of health promotion services as a preventative measure in relation to STI’s, unplanned pregnancies and HIV Areas that require additional health promotion included Improved sexual health promotion and education for menopausal changes and training local businesses regarding sexual health especially in the area of HIV the where reassurance is required in terms of HIV disclosure.
Improve sexual health promotion in schools (5) There is a lack of education regarding contraception and STIs and child sexual exploitation (CSE). Sexual and Relationships (SRE) in schools should be improved-it should be a requirement. A central, quality controlled package for schools and colleges, parents on SRE ensuring aspects of CSE and consent are covered (age appropriate) Concerns were raised about HIV and AIDS education in sixth form. Misconceptions are very prevalent and there is a lack of information. Knowledge is better regarding STIs as THT have a Health Promotion Worker but there is not enough HIV education. Concern was raised that there is insufficient support offered to children living with HIV including psychological issues, adherence to medication and coping with stigma. Recommendation regarding sexual health promotion for schools Sexual health promotion for schools should be better coordinated HIV education should be introduced from age 8 and generally be included with other illnesses e.g. cancer. Design specialist HIV health promotion and support for children living with HIV 10.6 Children and Young People
Young People Clinics The Young People Only Drop-in Clinic has a focussed and sensitive understanding approach Recommendation Drop in clinics-that specifically offer targeted advice for young people should be available from accessible locations in Buckinghamshire every weekday.
Safeguarding (2) There are more vulnerable children than is recognised. It is important to optimise communication between health and social care. There are well-established safeguarding Social Care pathways they include how to request a review if there is a disagreement regarding the outcome of safeguarding meeting.
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Prevention of Child Sexual Exploitation (CSE) (4) Buckinghamshire Sexual Heath staff are very aware of CSE and very sensitive to vulnerable girls and boys (although reception is not always aware). A reduced waiting list time for consultations/fitting for IUD/implant some wait several weeks. (3)– Ideally it should be done on the same day as the consultation as many who are high risk refuse to return. Try to deliver all services from same place and ideally single albeit long clinic session A greater level of provision for highly vulnerable young people is required i.e. child sexual exploitation, fast-track for R U Safe clients, without having to go through a Clinic Manager. A discreet way introduced for young people identified as vulnerable to CSE to be able access services on a fast- track basis, with or without their R U Safe worker. E.g. Suggested a card be issued to R U Safe clients Recommendation a card system a discreet way for child sexual exploitation (CSE) to be identified RU Safe- Recommend a “Bucks FastTrackMe” card should be introduced and given to children / young people who have been identified as vulnerable so when they make contact with the service they are fast-tracked and offered sufficient time to sort them out at one appointment rather than expecting them to return. The FastTrackMe card-could have RUSafe telephone numbers on the back. All sexual health staff should be aware of and where appropriate reporting to the Multi-Agency Safeguarding Hub (MASH) (based with the police). The agency is responsible for- children who are missing, SERAC (Sexual Exploitation Risk Assessment Conference), Social services, Police, sexual health, child protection, safeguarding referral, RUSafe, CAMS, Addaction, youth offending service, MARAC domestic violence support etc. 10.7 Hard to Reach Groups
Black African Communities- Concerns were raised regarding gaining meaningful access or engaging with Black African Communities as it is hard to gain meaningful access or engage (1)
Hard to Reach Vulnerable People Overall it has been reported that there are good outreach strategies which reach vulnerable individuals and groups who may not necessarily receive any sexual health input e.g. homeless-drop in clinics. SMART-drug and alcohol, gay and bisexual men (GBM) have no venues in Buckinghamshire, sex workers forum, learning difficulties workshops For example during National HIV Testing Week-a University photo booth was introduced that included prevention messages. In addition the photo booth advertised free confidential HIV testing. During the promotion he week 45 tests were undertaken as direct results of the advertising; all 45 tests were negative allaying the anxiety of the worried well students. Recommendation regarding black African communities Future services need to utilise experienced sexual health outreach workers to optimise accessing the black African communities and other hard to reach at risk groups 10.8 HIV Social Care HIV social care has existed in the Council since 2004 and since 2010 HIV social care has worked closely with THT outreach workers. Within social care during this time a single individual has been
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10.11 Key Recommendations from the Stakeholder Interviews Integrate Services Further A Central Organisational Hub and Spoke Model is required with clear integrated pathways Integrate the Chlamydia Screening programme into the wider community sexual health services. Improved Communications Improve GP communications and integration levels-more shared updated and learning, more opportunities to link up. GPs with a Special Interest (GPwSI), especially those GPs located in the North of Bucks, to be more involved in level 2 outreach being funded via a LES
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An awareness raising campaign is required for the public, potential and current clients and NHS staff including primary care staff. Information Technology Introduce a central single booking system for sexual health appointments Increase the use of new technologies in sexual health prevention programs Referral When SH services are tendered it is important that the service specification ensures that the HIV specialist clinical service remains integrated with other sexual health services with clear referral pathways and some HIV specialist workers who maintain the expertise regarding HIV care in the community benefits and act as a direct link and to other sexual health staff. Introduce a fast tracked referral system between community pharmacists and sexual health services Schools SH Promotion Sexual health promotion for schools should be better coordinated. HIV education should be introduced from age 8 and generally be included with other illnesses e.g. cancer. Design specialist HIV health promotion and support for children living with HIV Young People Drop in clinics-that specifically offer targeted advice for young people should be available from accessible locations in Buckinghamshire every weekday. RU Safe- Recommend a “Bucks FastTrackMe” card should be introduced and given to children / young people who have been identified as vulnerable so when they make contact with the service they are fast-tracked and offered sufficient time to sort them out at one appointment rather than expecting them to return. The FastTrackMe card-could have RU Safe telephone numbers on the back. Outreach Future services need to utilise experienced sexual health outreach workers to optimise accessing the black African communities and other hard to reach at risk groups. Outreach prevention and health promotion services should target the MSM and sex workers in Buckinghamshire utilising new technologies. SH Training Staff training where possible should be integrated with shared CPD updates – to ensure all service providers get to know each other and have a shared understanding of the care pathways. Sexual Health Training and CPD should be promoted via accredited sexual health website Improve the skills of community pharmacists including their contraceptive knowledge. All sexual health staff should be aware of and where appropriate reporting to the Multi-Agency Safeguarding Hub (MASH) (based with the police). The agency is responsible for- children who are missing, SERAC (Sexual Exploitation Risk Assessment Conference), Social services, Police, sexual health, child protection, safeguarding referral, RU Safe, CAMS, Addaction, youth offending service, MARAC domestic violence support etc.
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11 Bucks Sexual Health Staff Survey 2015 – Summary This is a summary of the Bucks Sexual Health Staff Survey. To review the full survey please see Appendix 1 11.1 Distribution The Buckinghamshire Sexual Health Staff Survey was sent to all staff in Buckinghamshire Health Trust, Terrence Higgins Trust and Brook Sexual Health Services. 11.2 Number of staff working from each Sexual Health Site Bucks Health Trust - 41 Terrence Higgins Trust - 12 Brook Clinic - 5 11.3 Sexual Health Staff Survey Results There was a very good response rate of 76% with 44 members of staff out of the total 58 members of staff completing the survey. There was good representation of staff from all the Sexual Health Clinics; some members of staff work at more than one clinic. The majority of staff who the completed the survey were clinical. Only 20/44 members of staff responded to the demographic questions. Of these 85% were female 90% were aged 30 to 64; 5 members of staff had some type of disability; 50% were Christian; all staff were from a white background; 65% were heterosexual 10% bisexual, 5% Gay and 20% preferred not to say. The top five key components of a successful health sexual health service were identified as being 1. Confidentiality 2. Integrated Sexual Health Services 3. Evidence-Based Clinical Standards 4. Robust Safeguarding Arrangements 5. Access to Ongoing Training And Development for All Staff The majority of sexual health staff considered there was sufficient booked appointments available, there was sufficient time allocated for new and follow-up appointments and that the current services were sufficiently flexible to allow complex patients to be managed. More than half of the staff (57%) considers there should be more walk-in clinics and the remaining staff (44%) considered additional walk-in clinics were not required. All members of staff with the exception of one member considered the quality of training they received was either very good or good. All members of clinical staff considered their training for fitting IUDs, a IUS and implants was either very good or good. The vast majority of clinical staff considered their STI management training had been very good or good. The only area where four members of staff considered training to only be OK was for HIV training. Staff Sexual Health Training was provided to the staff by a large number of different of sexual health training providers. All clinical staff stated they were able to keep up-to-date with their training and competencies. The majority of staff considered that they were supported in receiving appropriate training for their job role (94%). Two members of staff considered their training had not been supported (6%).
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All the staff understands the importance of collecting data and its use to Public Health England and commissioners. Suggested ways that electronic patient records could be improved Avoid repetition IT systems that integrated Levels 1, 2 and 3 Ensure a high level of security and confidentiality Standardised easy ways to enter notes including BP BMI Sufficient numbers of computers Standardisation of data entry Include a spell checking system Ensure good IT training of staff
Strengths of Buckinghamshire Sexual Health Services included the following Location of services Flexibility of services Improved integration between the GUM and contraception Good communication between service Levels Evidence-based services Knowledgeable friendly committed staff Sexual health services that are integrated with HIV services Good staff satisfaction Good referral pathways between the different levels of service Good sexual health website Dedicated Young Persons clinics Multidisciplinary approach
Concerns regarding local sexual health services in Buckinghamshire included the following Fragmentation of GUM and HIV services if they are commissioned by different providers Opening times of services are variable and may be confusing to the public Lack of out of hours services including early morning, evening and weekends Improved staff training to ensure that they are fully integrated into all aspects of sexual health Poor referral pathways to mental health services Lack of psychosexual services in Buckinghamshire despite demand for this service Computer systems are not linked between the services Primary care lacking knowledge about referral pathways to SARC, Level 2 or Level 3 services Some primary care services are not offering all the services they are contracted to under the GMS Contract Sex and Relationships Education (SRE)in schools needs to be improved
Suggestions for how sexual health services could be improved in Bucks included Fully integrated GUM and contraception services A centralised appointment booking service that covers all levels of sexual health services Improved opening times especially early-morning late evening and weekends Improved services for all women requesting abortions e.g. access to bpas Improved referral pathways to mental health services Improved integration of Level 2 and Level 3 services
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Improved locations of community clinic’s clinics in rural parts of Buckinghamshire Improve training to ensure all clinical staff are dual trained to offer integrated services Improved sex education in schools offered by well trained staff Improved utilisation of IT to offer online assistance to the public and clients Improved health promotion services that advertise emergency contraception Establishing psychosexual counselling services within Buckinghamshire Purchasing scanning equipment that assists in the removal of deep implants More outreach prevention initiatives
Suggestions regarding how Sexual Health Promotion should change the next five years Increase number of colleges and schools outreach Increase the number of schools taking part in the condom C-Card scheme. Utilise new technologies to promote prevention messages Ensure HPV vaccination is available for young boys Improve communications campaigns to promote prevention messages A multiagency approach to promote prevention messages focus more on consent Focus on sexual health prevention messages in schools and involve parents Improve skills of staff to ensure they are competent to care for vulnerable young people Carry out a workforce review and identify how retirement will impact on skill mix and capacity Work more closely with primary care teams and offer constructive training and support to ensure they have the capacity to deliver level 1 and in some cases level 2 services. Delivery of fully integrated Level 1 and Level 2 services Fund prevention programmes that are targeted at vulnerable children About half the staff knew how to access educational materials in different languages and formats (54%). 78% of staff are able to access interpreting and translation services when required. People with mental health conditions, learning impairments and victims of sexual assault were considered to require longer appointments. In addition homeless people and people with drug and alcohol misuse problems were also considered to require longer appointments. It was considered that young people under 25 years require specialist clinics in addition some staff considered victims of sexual assault, sex workers, and people with drug and alcohol misuse, also need specialist clinics. The many members of staff of staff considered no specialist services were required for MSM or lesbian, gay, bisexual and transgender (LGPT). In addition some staff considered the homeless, young people under 25 and sex workers did not require specialist services. Only half of the staff responded to this question. In relation to the role that Bucks sexual health network should be moving forward to suggestions included the following. Integrated services Continued provision and access for sexual health screening for population of Buckinghamshire. Health promotion in secondary schools and colleges. Better communication between schools To steer the services and develop partnership working Ensure we provide the best most efficient service we can Meeting collaboratively at workshops, this has been really useful in the past. Maintaining the excellent SH website Improved opening times 7am and 10pm Mon-Fri and on 9-3 on Saturdays Improved coordination across the service.
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Improved premises Offer more contraception clinics in South Bucks District Council area Concerns were raised regarding how changes in the sexual health commissioning arrangements at national level could impact on Buckinghamshire Sexual Health Services Fragmentation of the service Damage to the voluntary sector HIV split from other services Sexual health being a low priority Concerns regarding privatisation of the NHS All staff considered there is good partnership working across Buckinghamshire between NHS England, Local Authorities, CCGs and sexual health providers. However only 14/30 members of staff responded to this question. 71% of staff that responded to a question regarding commissioning sexual health services stated they had not been any specific issues. Only 14 members of staff responded to this question. No staff had any issues regarding resource allocation of sexual health services. Only 12 staff responded to this question Additional concerns included staff being anxious regarding the tendering process and a suggestion regarding whether drug services could be commissioned to screen for STIs.
Staff’s vision about how services could be improved in the future included the following. Fully integrated services Improved funding Improved premises Improved outreach to colleges and schools Merging sexual health and drugs and alcohol services as a one-stop shop Integrated Hep C and HIV treatment pathways Additional training with primary care Up-to-date IT systems Improved publicity Mobile services delivered to schools and colleges via a bus
KEY RECOMMENDATIONS from the Staff Survey Ensure the STI and contraception services become fully integrated and HIV remains fully integrated Improve communication between Level 2 and Level 3 services Improve the record-keeping IT systems Promote a multidisciplinary approach that includes strong links with drug and alcohol services Promote multidisciplinary training Improve training for primary care staff and community pharmacists Improve and expand prevention interventions in colleges and schools Increase outreach services and target locations that have poor access to sexual health services
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12 Summary Bucks Sexual Health Public Survey 2015 This is a summary of the Bucks Sexual Health Public Survey. To review the full survey and the distribution strategy please see Appendix 2. The Draft Buckinghamshire Sexual Health Public Survey 2015 was designed by PHAST and modified by the commissioners. 12.1 Distribution Strategy The survey was advertised to the public by alerting key stakeholders by placing the link on websites and sending a SurveyMonkey link via email; a list of the people and groups altered is listed below. The survey link was also advertised via twitter sites that are also listed. In addition paper copies of the survey were distributed for one to one completed and group completion. Reminders were sent on 2 occasions separated by a 2 week period General Public Websites/Emails/Circulation to Public One to One/group work with clients Original Tweets and Number of Followers – Retweeted for a Second and Third Time 12.2 Summary Results Bucks Sexual Health Services Public Survey 2015 There was a very good response to the Public survey; 230 members of the public completed the survey. The majority completed the survey online and 55 members of the public completed a paper survey. 54% of the respondents had used sexual health services in the UK and 49% of respondents had used sexual service health services in Buckinghamshire. 86% of the respondents lived in Buckinghamshire, of these, 35% lived in Aylesbury Vale, 28% lived in South Bucks, 25% lived In Wycombe and 12% lived in Chiltern. 173/230 respondents who answered the demographic questions 56% were female 41% were male 2% were transgender and 2% preferred not to say. 24% were aged 16 to 19, 43% were aged 20 to 2923% were aged 30 to 49 4% were aged 50 to 64 and 2% were aged 65 to 74. Thirteen percent reported they had a disability. 45% reported they had no religion, 38% stated they were Christian, 2% stated they were Muslim, 2% stated they were Hindu and 1% stated they were Buddhist. 73% were from a white background, 11% were Asian, 10% were from black background, 6% were mixed race, and 1% was from an Arab background. The majority of respondents rated sexual health services in Buckinghamshire as “good” or “very good”. Rating scores for doctor’s surgery included more “poor” or “very poor” compared to the other services. Please see the detailed table for specific sites. The majority of respondents had been informed about sexual health services by the GP or practice nurse. The sexual health website was also identified by a few respondents. Only a few respondents mentioned school or a school nurse been a source of information. Most of the respondents had made an appointment at their doctor’s surgery; drop-in was more likely at SHAW, colleges, Brook, Brookside and community pharmacy. Most respondents sought the opening times during weekdays were adequate, about half responded evening appointments after 6pm and weekend appointments were inadequate. The majority of respondents considered that the services they received were excellent good or ok. A small number considered they were poor or very poor. The clinic opening times were identified as poor more frequently than any other aspect of the sexual health services. All the comments regarding what clients liked best about sexual health services in Buckinghamshire were complimentary; the most frequent statements were friendly, helpful, non-judgemental staff, confidentiality being respected. The vast majority of comments regarding what clients would like to
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KEY RECOMMENDATIONS from Public Survey Increase opening times especially evenings and weekends Review location of services especially in relation to at risk and hard to reach groups Review confidentiality procedures in relation to waiting rooms Introduce new technologies to promote prevention messages and signposting of services Improve primary care training to improve their delivery of sexual health services
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13 BHT User Satisfaction Survey – Summary Results 13.1 Buckinghamshire Healthcare NHS Trust 2013/14 This is a summary of the Patient Satisfaction Survey of Buckinghamshire Healthcare NHS Trust 2013/14. To review the full survey results please see Appendix 4 The patient survey is conducted annually by all sexual health services and is a requirement of the service specification. Surveys were distributed in the clinics over a period of 4 weeks in the year commencing April 2013. The findings from the Buckinghamshire Healthcare NHS Trust Service are summarised below.
13.2 Results Annual Patient Satisfaction Survey
Figure 117. Sexual Health Patient Survey Results-- April 2013- March 2014
A total of 77 service users completed the sexual health patient survey which took place during the year April 2013 to March 2014. The number of service users completing the Sexual Health Patient Survey was higher for GUM services (57 = 75%) compared to contraceptive services (24%). only 20 contraception users completed the sexual health patient survey, there were 17 individuals from Brookside and 3 individuals from SHAW. No questionnaires were completed at ‘Contraception, YES’. This should be taken into account when reviewing the key findings.
Summary Patient Survey Results Over 60% of GUM service users knew what would happen to them when they attended the clinic. Only 41% of contraception users at Brookside knew what would happen to them and none of the three users at contraception Shaw knew what would happen to them. Over 80% of GUM service users found the clinic easy to find. 70% of contraception Brookside users found it easy to find and only 33% of contraception SHAW found the clinic easy to find. The date and time of the appointment was more convenient for the GUM user. Only 59% of contraception Brookside found the date and time convenient and only 33% of contraception Shaw found the date time convenient. 70% of service users attended sexual health services on either a Monday or Tuesday. About 30% attended during Wednesday Thursday Friday. There were no attendances on Saturday. All the service users attending GUM SHAW and GUM Brookside and Contraception Shaw found the reception area welcoming. Only 65% of service users found Contraception Brookside reception area
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14 THT User Satisfaction Survey - Summary Results 14.1 Summary Results from Terrence Higgins Trust (THT) Level 2 Service This is a summary of the Patient Satisfaction Survey of Buckinghamshire Healthcare NHS Trust 2013/14. To review the full survey results please see Appendix 3
Source Terence Higgins Trust 2014 The patient survey is conducted annually by all sexual health services and is a requirement of the service specification. Surveys were distributed in the clinics over a period of 4 weeks in the year commencing April 2013. The findings from the Buckinghamshire Healthcare NHS Trust Service are summarised below.
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Overall, the level of satisfaction across the county was considered as excellent across the majority indicators. The clinic opening times received lower scores indicating that opening times should be reviewed when planning future services. The cleanliness of the waiting area needs to be reviewed in Buckingham. Buckingham and Wye Valley scored less highly compared to Burnham, Chalfont and Chesham in relation to booking/privacy / dignity/respect /courtesy at reception.
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15 Key Findings and Recommendations 15.1 Buckinghamshire Sexual Health Services Buckinghamshire Sexual Health Services are targeted at the two large population centres in Aylesbury and High Wycombe and to the South of Wycombe bordering Slough where there is a higher population density. Services are also provided in Buckingham to the North. Services are well located to target the most deprived areas of the county. GUM, HIV and Contraception L3 services are located in Aylesbury and High Wycombe and there is a mix of community outreach integrated L2 services across the county. Some clinics require appointments to be made in advance whereas others are drop-in services. Current configuration of sexual health services in Buckinghamshire has been operational since 2012. Services are provided by 3 providers as well as Level 2 services being provided by some community pharmacies and general practice in Buckinghamshire. The 3 current providers are: Brook based at Wheelden House Buckingham Buckinghamshire Healthcare NHS Trust Terrence Higgins Trust (THT)
The percentage of total attendances occurring at each site in Buckinghamshire in 2014-15 is: 48.3% SHAW; 35.7% Brookside; 14.5% Terrence Higgins and 1.6% Brook. The number of first attendances and rebooks at sexual health services in Buckinghamshire have increased from 9,689 in 2009-10 to a peak of 12,921 in 2013-14(+33%) with a slight decrease to 12,642 in 2014-15 (-2%). The number of follow up attendances at sexual health services in Buckinghamshire have decreased from 4,865 in 2009-10 to 3,738 in 2014-15 (-23%). The total number of attendances at sexual health services in Buckinghamshire have increased from 14,544 in 2009-10 to a peak of 17,334 in 2013-14 (+19%) with a slight decrease to 16,380 in 2014-15 (-5%). The percentage of total attendances at sexual health services in Buckinghamshire that are follow ups has decreased from 33% in 2009-10 to 23% in 2014-15. In 2013-14 the percentage of total attendances that are follow ups at different locations is: Brook 35%; SHAW 25%; Brookside 22% and Terrence Higgins 17%.
KEY RECOMMENDATIONS from the Site Activity The total number of attendances at sexual health services in Buckinghamshire should be monitored closely to ensure it does not follow last year’s trend and continue to decrease. Although to have a reducing number of follow-up appointments can be a positive finding; the decreasing number and percentage of follow up attendances at sexual health services in Buckinghamshire should be investigated in relation to the overall decrease in attendances. The percentage of total attendances that are follow-up varies greatly from site to site and should be investigated further. Out-of- Hours Opening There is one contraception clinic open at Brookside Aylesbury between 6.00- 8.00pm on a Monday. There are no STI clinics available late evenings in Aylesbury. The SHAW clinic offers two afternoon STI testing/GUM clinics on a Monday and Wednesday that are open between 1.00 pm- 7.00pm. The Shaw offers contraception clinics on Tuesday open between 5.45 pm – 7.45 pm and Thursday open between 5.45 pm – 7.30pm. There are no STI services available early mornings after 8.00pm or during weekends/bank holidays. It is noticed that Terrence Higgins Trust offers one late clinic in
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Chalfont and Gerrards Cross on Wednesday open 6.00pm- 9.00pm. Other than this clinic, there are no other late evening clinics or weekend clinics offered.
Recommendation It is recommended that future service specification review the opening hours for STI/GUM and Contraception Services. Future Integrated Sexual health Services should be available on all weekday evenings and during weekends and bank holidays. 15.2 Buckinghamshire Demographics The population of Buckinghamshire is concentrated to the south of the county with two large population centres in Aylesbury and High Wycombe and one smaller centre to the north in Buckingham. Buckinghamshire has a similar gender and age profile to England, except for a slightly smaller percentage of the population in the 20-34 age category that is 3.8% lower than England. (England 20.3%) (Buckinghamshire 16.5%). This age range is often associated with a higher rate of STIs and should contribute to Buckinghamshire having lower STI rates than England. From 2015 to 2020 the population of Buckinghamshire is set to increase from 522,596 to 543,787 (+21,191) with an annual growth rate of 0.8%. During the same timeframe the sexually active population aged 15-64 is set to increase by 4,674 with an annual growth rate of 0.29%.
Recommendation: Sexual health services should provide additional appointments to cope with the increased number of sexually active people in Buckinghamshire.
Deprivation in Buckinghamshire is lower than the England average, however about 10-5% (10,300) children live in poverty. Buckinghamshire has a few small areas of relatively high deprivation located around the two main population centres of Aylesbury and High Wycombe.
The Buckinghamshire 2015 Health Profile demonstrates that Buckinghamshire has: Good community indicators Good child and young person health Average adult health and lifestyle Good disease and poor health indicators (apart from hip fractures that is average) Good to average life expectancy indicators
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15.3 Buckinghamshire Sexual Health Profile 2015
Comment boxes are colour coded to show if the indicator is than England’s average value or than England’s average value. 15.3.1 All new STIs STI testing rate (excluding Chlamydia aged < 25) / 100,000 (2013): Buckinghamshire had an STI testing rate of 11,412/100,000 this is worse than the England average rate of 14,685/100,000 and worse than the Thames Valley average rate of 13698/100,000. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. From 2012 to 2013 Buckinghamshire’s rate has remained worse than England’s average rate and worse than the Thames Valley average rate.
Recommendation: Buckinghamshire should increases its testing rate for STIs (in all age ranges) to match or exceed England’s average values, this will ensure that the true prevalence rate of STIs in Buckinghamshire does not go unchecked and allow a true comparison of STI diagnosis rates to be made. All new STI diagnoses (excluding Chlamydia aged <25) / 100,000 (2013): Buckinghamshire had a rate of 596/100,000 this is better than the England average rate of 832/100,000 and better than the Thames Valley average rate of 701/100,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data. From 2012 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate.
Key Result: In Buckinghamshire the testing rate for STIs (age <25) is low compared to England’s average rate, it is therefore not surprising that the STI diagnosis rate (age <25) is also low in Buckinghamshire compared to England’s average rate. STI testing positivity (excluding Chlamydia aged <25) (%) (2013): Buckinghamshire had a value of 5.2% this is worse than the England average value of 5.7% but better than the Thames Valley average value of 5.1%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. From 2012 to 2013 Buckinghamshire’s percentage has remained worse than England’s average value but better than the Thames Valley average value.
Key Result: Buckinghamshire should expect a 29% rise in STI diagnosis rates if it increases its STI testing rates to a similar level as England’s average rate. STIs in Buckinghamshire Local Authorities (LASER Data) All 4 local authorities in Buckinghamshire are ranked from middle too good for the rate of new STI diagnosed per 100,000 residents: Wycombe (639.3) Aylesbury Vale (499.5), South Bucks (502.7), Chiltern (366.8) when compared to an England average rate of 810.9. Approximately 53% of STIs diagnosed are in males and 47% in females. Approximately 53% of STIs are diagnosed in young people aged 15-24. A lower percentage of MSM are diagnosed in Wycombe (7%) compared to other Districts (9- 14%). South Bucks and Wycombe have a much higher % (12%) of new STIs diagnosed in people who were born overseas compared to other Districts (6%) Although the majority of all STIs diagnosed are in White Ethnic groups there is a much higher diagnosis rate of STIs in black ethnic groups (higher in 3 of the 4 LAs than the England average).
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There is a higher reinfection rate with STIs for males in South Bucks, Wycombe and Aylesbury Vale compared to England average. There is a higher reinfection rate with STIs for females in Chiltern and South Bucks compared to England average. 15.3.2 Chlamydia Chlamydia detection rate / 100,000 aged 15-24 (2013): Buckinghamshire had a rate of 1232/100,000 this is worse than the England average rate of 2016/100,000 and worse than the Thames Valley average rate of 1434/100,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data. From 2012 to 2013 Buckinghamshire’s rate has remained worse than the England average rate and worse than the Thames Valley average rate
Recommendation: Buckinghamshire should increases its testing rate for Chlamydia (age 15-24) to match or exceed England’s average value, this will ensure that the true prevalence rate of Chlamydia in Buckinghamshire does not go unchecked and allow a true comparison of Chlamydia diagnosis rates to be made. Chlamydia proportion aged 15-24 screened (2013): Buckinghamshire had a value of 15.5% this is worse than the England average value of 24.9% and worse than the Thames Valley average value of 20.2%. Overall Buckinghamshire was ranked 11 out of 13 comparator areas with data. From 2012 to 2013 Buckinghamshire’s value has remained worse than the England average value and worse than the Thames Valley average value
Buckinghamshire should expect a 61% rise in chlamydia detection rates if it increases the percentage of the population aged 15-24 tested for chlamydia to a similar level as England’s average value. Chlamydia in Buckinghamshire Local Authorities (LASER Data) The percentage of young people aged 15-24 that were tested for chlamydia is low in all districts in Buckinghamshire compared to the England average of 24.9%, Chiltern (10.4%), Wycombe (13.6%), South Bucks (15.3%) Aylesbury Vale (19.8%). (15.5% in Buckinghamshire) Overall Buckinghamshire had an 8% positivity rate for young people aged 15-24 tested for chlamydia with a higher value of 10% in Wycombe. 15.3.3 Gonorrhoea Gonorrhoea diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 20.5/100,000 this is better than the England average rate of 52.9/100,000 and better than the Thames Valley average rate of 28.8/100,000. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate. 15.3.4 Syphilis Syphilis diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 1.8/100,000 this is better than the England average rate of 5.9/100,000 and better than the Thames Valley average rate of 2.4/100,000. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate (except 2010 when a similar rate to Thames Valley was achieved).
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15.3.5 Genital warts Genital warts diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 113/100,000 this is better than the England average rate of 133.4/100,000 and better than the Thames Valley average rate of 126.4/100,000. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate. 15.3.6 Genital herpes For genital herpes diagnosis rate / 100,000 (2013): Buckinghamshire had a rate of 45.7/100,000 this is better than the England average rate of 58.8/100,000 and better than the Thames Valley average rate of 52.0/100,000. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate and better than the Thames Valley average rate. 15.3.7 HIV HIV diagnosed prevalence rate / 1,000 aged 15-59 (2013): Buckinghamshire had a rate of 1.34/1,000 this is lower than the England average rate of 2.14/1,000 and lower than the Thames Valley average rate of 1.6/1,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data. From 2010 to 2013 Buckinghamshire’s rate has remained lower than England’s average rate and lower than the Thames Valley average rate. HIV late diagnosis (%) (PHOF indicator 3.04) (2011-13): For HIV late diagnosis (%) (PHOF indicator 3.04) (2011-13): Buckinghamshire had a value of 47.5% this is similar to the England average value of 45% and similar to the Thames Valley average value of 47.6%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. From 2009-11 to 2011-13 Buckinghamshire’s value has fluctuated at approximately 47% to 50% putting it on the border of a normal to less than average result.
Recommendation: The percentage of HIV diagnoses made at a late stage in Buckinghamshire is very close to the 50% threshold and should be monitored closely to ensure it reduces to less than 25% over the next 3-5 years. For HIV testing uptake, men (%) (2013): Buckinghamshire had a value of 85.0% this is similar to the England average value of 84.9% and similar to the Thames Valley average value of 83.8%. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data. In 2009 Buckinghamshire had a better value than England and from 2010 to 2013 Buckinghamshire’s value has remained similar to England average value. HIV testing coverage, men (%) (2013): Buckinghamshire had a value of 75.5% this is worse than the England average value of 77.5 % and worse than the Thames Valley average value of 77.4%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. In 2009 and 2010 Buckinghamshire had a similar value to England but from 2011 to 2013 Buckinghamshire’s value has remained worse than England average value.
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HIV testing uptake, women (%) (2013) Buckinghamshire had a value of 73.4% this is worse than the England average value of 75.8% but better than the Thames Valley average value of 63.2%. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s value has remained worse than England’s average value. HIV testing coverage, women (%) (2013) Buckinghamshire had a value of 66.9% this is better than the England average value of 65.6% and better than the Thames Valley average value of 62.8%. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data. In 2009 Buckinghamshire had a similar value to England but from 2010 to 2012 Buckinghamshire’s value was worse than England and has only got better than England’s average value in 2013. HIV testing uptake, MSM (%) (2013): Buckinghamshire had a value of 94.7% this is similar to the England average value of 94.8% and similar to the Thames Valley average value of 94.7%. Overall Buckinghamshire was ranked 9 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s value has remained similar to England’s average value. HIV testing coverage, MSM (%) (2013): Buckinghamshire had a value of 79% this is worse than the England average value of 86.1% and worse than the Thames Valley average value of 85.8%. Overall Buckinghamshire was ranked 12 out of 13 comparator areas with data. From 2009 to 2011 Buckinghamshire had a similar value to England but from 2012 to 2013 Buckinghamshire’s value has remained worse than England average value.
Recommendation: Buckinghamshire should improve HIV testing uptake and coverage for all groups but especially improve uptake for women and improve coverage for men and MSM. HIV in Buckinghamshire Local Authorities (LASER Data) The HIV prevalence rate in all Districts is Buckinghamshire is lower than the England average. Wycombe has a slightly higher prevalence rate (1.6) compared to other Districts Of the adults receiving HIV care: 39% Wycombe, 36% Aylesbury, 14% South Bucks and 11% Chiltern 61% Male, 39% Female, 48% White, 38% Black African, 61% Heterosexual , 31% MSM, Buckinghamshire (47.5%) has a slightly higher percentage of HIV diagnoses that were made at a late stage of infection than the England average (45%). Chiltern (75%) and Wycombe (53%) have a higher percentage of HIV diagnoses that were made at a late stage of infection than South Bucks (45%) and Aylesbury Vale (40%). Wycombe that has the highest rate of diagnosed HIV compared to the other Districts. South Bucks and Aylesbury Vale have lower uptake and coverage of HIV testing at eligible GUM clinics compared to England’s average.
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15.3.8 Conception Under 18s conception rate / 1,000 (PHOF indicator 2.04) (2013): Buckinghamshire had a rate of 17.2/1,000 this is better than the England average rate of 24.3/1,000 and similar to the Thames Valley average rate of 16.8 /1,000. Overall Buckinghamshire was ranked 8 out of 13 comparator areas with data. From 1998 to 2013 Buckinghamshire’s rate has remained better than England’s average rate.
Recommendation: Buckinghamshire should closely monitor Under 18 conceptions leading to abortion (%) to ensure they remain lower than the England average value to demonstrate good access to contraceptive services Conception in Buckinghamshire Local Authorities (LASER Data) Under 18 conception rates are lower in Chiltern (13.5%) and South Bucks (16.5) than in Wycombe (17.9) and Aylesbury Vale (19.2) Under 16s conception rate / 1,000 (PHOF indicator 2.04) (2013): Buckinghamshire had a rate of 2.0/1,000 this is better than the England average rate of 4.8/1,000 and better than the Thames Valley average rate of 2.8 /1,000. Overall Buckinghamshire was ranked 2 out of 11 comparator areas with data. From 1998 to 2013 Buckinghamshire’s rate has remained better than England’s average rate. Under 18s births rate / 1,000 (2013): Buckinghamshire had a rate of 4.8/1,000 this is better than the England average rate of 7.8/1,000 and better than the Thames Valley average rate of 5.1 /1,000. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data. From 2009 to 2013 Buckinghamshire’s rate has remained better than England’s average rate. For under 18s conceptions leading to abortion (%) (2013): Buckinghamshire had a value of 55.1%; this is similar to the England average value of 51.1% and similar to the Thames Valley average value of 54.8%. Overall Buckinghamshire was ranked 7 out of 13 comparator areas with data. From 1998 to 2012 Buckinghamshire’s value has remained higher than England’s average value, but in 2013 Buckinghamshire had a similar value to England.
Recommendation: Buckinghamshire should closely monitor Under 18s conceptions leading to abortion (%) rates to ensure they remain higher than the England average value.
15.3.9 Abortion The Department of Health has suppressed the Local Authority level data at source for Buckinghamshire. But data is available for Aylesbury Vale and Chiltern CCGs and using this data, the populations can be extrapolated and rates for Buckinghamshire calculated The rate of Legal abortions per 1000 women for all ages (2014): Buckinghamshire had a rate of 13.9/1,000 this is better than the England average rate of 16.5/1,000 and similar to the Thames Valley average rate of 14.3 /1,000. Overall Buckinghamshire was ranked 7 of 12 comparator areas with data.
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The rate of legal abortions per 1000 women aged under 18 (2014): Buckinghamshire had a rate of 8.0/1,000 this is better than the England average rate of 11.1/1,000 and similar to the Thames Valley average rate of 8.4 /1,000. Overall Buckinghamshire was ranked 3 of 8 comparator areas with data. Abortions under 10 weeks (%): Buckinghamshire had a value of 82.1% this is better than the England average value of 81.1% but lower than the Thames Valley value of 84.1%. Overall Buckinghamshire was ranked 6 out of 13 comparator areas with data. Under 25s repeat abortions (%): Buckinghamshire had a value of 28.0% this is worse than the England average value of 27.0% and worse than the Thames Valley average value of 26.3%. Overall Buckinghamshire was ranked 12 out of 12 comparator areas with data.
Recommendation: Buckinghamshire should introduce new interventions for women under 25 having abortions to try and lower the very high rate of under 25s repeat abortions.
Buckinghamshire has a 47% Medical and 53% Surgical use of abortion methods, which is similar to England values of 50% Medical and 50% Surgical and Thames Valley values of 43% Medical and 57% Surgical. 37% of legal abortions in Buckinghamshire are repeat abortions. With 28% repeat in under 25 age group and 44% repeat in 25 and over. Similar values are achieved in England and Thames Valley. 4.5% of legal abortions in Buckinghamshire are purchased in NHS Hospitals, 92% are purchased in NHS independent sector and 3% are purchased privately. The privately funded percentage is slightly higher than the percentages achieved in England and Thames Valley. 82% of legal abortions in Buckinghamshire are 3-9 weeks gestation, 9% are 10-12 weeks gestation and 9% are 13+ weeks gestation. Similar percentages are achieved in England and Thames Valley.
15.3.10 Contraception GP prescribed LARC rate / 1,000 (2013): Buckinghamshire had a rate of 53.9/1,000 this is similar to the England average rate of 52.7/1,000 but lower than the Thames Valley average rate of 56.1/1,000. Overall Buckinghamshire was ranked 10 out of 13 comparator areas with data. From 2011 to 2012 Buckinghamshire’s rate has remained higher than England’s average rate, but in 2013 Buckinghamshire’s rate has slightly reduced and is now similar to England’s average rate
Recommendation: Buckinghamshire should closely monitor GP prescribed LARC rates to ensure they remain higher than the England average value. Emergency Hormonal Contraception There is a downward trend in the number of Emergency hormonal contraception (EHC) consultations currently taking place in community pharmacies from 673 in 2008/09 to 344 in 2013/14. For 2014/2015 Levonelle was supplied at 97% of all consultations, this is in comparison to 99% for 2013/14 and 98% for 2011/12.
Recommendation: The decline in EHC Pharmacy consultations should be investigated further.
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C-Card Scheme There has been a gradual decline of approximately 45% in the use of the C-Card scheme from approximately 375 in 2011-2014 to 200 in 2013-2014. This may be due to poor data submissions and requires further investigation. In all quarters users of the C –Card Scheme were as follows: Approximately 50% of clients are male and 50% are female. Approximately 75% of clients are aged 14-18 Approximately 80% (or more) were white and 20%(or less) were BME
Recommendation: The decline in the use of the C-Card scheme should be investigated further. 15.3.11 Chlamydia Screening Recommendation: Chlamydia screening was offered to only 17% of condom clients over the 4 year period; work needs to be undertaken during 2015/16 to increase the numbers routinely offered a chlamydia test via this service. 15.3.12 HIV in Buckinghamshire Local Authorities (LASER Data) South Bucks has a higher rate of LARCs prescribed in primary care to women aged 15-44 than the other Districts In Buckinghamshire LARCs account for 11.8% and oral contraception 87.6% of prescribed contraceptives
15.3.13 Domestic Violence and Sexual Related Violence Sexual offences rate / 1,000 (PHOF indicator 1.12iii) (2013-14): Buckinghamshire had a rate of 0.99/100,000; this is similar to the England average rate of 1.01/1,000 and similar to the Thames Valley average rate of 1.0/1,000. Overall Buckinghamshire was ranked 12 out of 13 comparator areas with data. From 2010/11 to 2012/13 the rate has remained lower than the England average rate but in 2013/14 the Buckinghamshire rate is similar to England rate. The rate for Buckinghamshire shows an increasing trend compared to England.
Recommendation: The sexual offences rate in Buckinghamshire should be closely monitored to ensure it does not exceed England’s average rates. Sexual Assault and Referral Centre (SARC) In Buckinghamshire from 2013/14 to 2014/15: Overall sexual offences have increased by 23% from 602 to 740 Rape has increased by 42% from 139 to 197 Sexual assault has increased by 37% from 192 to 263 Sexual activity has decreased by -25% from 171 to 129 Other sexual offences have increased by 51% from 100 to 151 Some of these increases may be due to improved reporting.
Recommendation: A review of sexual violence offences in Buckinghamshire should be undertaken to try to ascertain whether there is an actual increase in sexual offences in the county or whether this is a trend similar to other areas of UK where there is increased reporting of sexual offences. Barnardo's R-U-Safe? The total number of young people RU Safe worked with in Buckinghamshire during 2014-2015, was 198 (172 female and 26 male).
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The most common age group was 14 and 15 years old. Significantly, RU Safe also worked with 2 ten year old girls – this is the first year RU Safe have had to do this. The majority of RU Safe clients come from White British heritage, though there is some representation from Black Caribbean and Asian communities. Over the year 2014-2015, 6 of RU Safe female clients experienced pregnancy.
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15.4 Summary Recommendations Site Activity The total number of attendances at sexual health services in Buckinghamshire should be monitored closely to ensure it does not follow last year’s trend and continue to decrease. Although to have a reducing number of follow-up appointments can be a positive finding; the decreasing number and percentage of follow up attendances at sexual health services in Buckinghamshire should be investigated in relation to the overall decrease in attendances. The percentage of total attendances that are follow-up varies greatly from site to site and should be investigated further. Sexual and Reproductive Health Profile Indicators PHAST recommend that following Sexual and Reproductive Health Profile Indicators that are worse in Buckinghamshire than the England average values should be targeted for improvement: 9. STI testing rate (excluding Chlamydia aged < 25) / 100,000 10. STI testing positivity (excluding Chlamydia aged <25) % 11. Chlamydia detection rate / 100,000 aged 15-24 12. Chlamydia proportion aged 15-24 screened 13. HIV testing coverage, MSM (%) 14. HIV testing uptake, women (%) 15. HIV testing coverage, men (%) 16. Under 25s Repeat abortions (%)
PHAST recommend that following Sexual and Reproductive Health Profile Indicators that are ranked in the bottom 5 when compared to 12 surrounding and comparator areas should be targeted for improvement. 10. Sexual offences rate / 1,000 (PHOF indicator 1.12iii) 11. GP prescribed LARC rate / 1,000 12. HIV diagnosed prevalence rate / 1,000 aged 15-59 13. All new STI diagnoses (excluding Chlamydia aged <25) / 100,000 14. HIV testing uptake, MSM (%) 15. Under 18s conception rate / 1,000 (PHOF indicator 2.04) 16. Cervical cancer registrations rate / 100,000 17. HIV testing coverage, women (%) 18. Syphilis diagnosis rate / 100,000
PHAST recommend that following Sexual and Reproductive Health Profile Indicators that have downward converging trends towards England’s average value should be monitored closely to ensure they do not diminish further: 7. Under 18s conception rate / 1,000 (PHOF indicator 2.04) 8. Under 18s conceptions leading to abortion (%) 9. GP prescribed LARC rate / 1,000 10. Sexual offences rate / 1,000 11. Cervical cancer registrations rate / 100,000 12. Pupil absence (%)
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A low diagnosis rate will not always be indicative of low prevalence rates, as the higher the percentage of the population that is tested for any STI the higher the diagnosis rate will be. All diagnosis data should therefore only be considered with close examination of test coverage and uptake in each area and in each demographic group.
STI Testing Buckinghamshire should increases its testing rate for STIs (in all age ranges) to match or exceed England’s average values, this will ensure that the true prevalence rate of STIs in Buckinghamshire does not go unchecked and allow a true comparison of STI diagnosis rates to be made. Buckinghamshire should increases its testing rate for Chlamydia (age 15-24) to match or exceed England’s average value, this will ensure that the true prevalence rate of Chlamydia in Buckinghamshire does not go unchecked and allow a true comparison of Chlamydia diagnosis rates to be made. HIV prevention The percentage of HIV diagnoses made at a late stage in Buckinghamshire is very close to the 50% threshold and should be monitored closely to ensure it does not diminish further. Buckinghamshire should improve HIV testing uptake and coverage for all groups but especially improve uptake for women and improve coverage for men and MSM. Under 18 conceptions Buckinghamshire should closely monitor under 18 conception rates to ensure they remain lower than the England average value. Buckinghamshire should closely monitor Under 18s conceptions leading to abortion (%) rates to ensure they remain higher than the England average value. Buckinghamshire should introduce new interventions for women under 25 having abortions to try and lower the very high rate of under 25s repeat abortions. LARC, EHC and C- Card Buckinghamshire should closely monitor GP prescribed LARC rates to ensure they remain higher than the England average value. The positive or negative reasons for the decline in EHC Pharmacy consultations should be investigated further. Sexual Offences The sexual offences rate in Buckinghamshire should be closely monitored to ensure it does not exceed England’s average rates. A review of sexual violence offences in Buckinghamshire should be undertaken to try to ascertain whether there is an actual increase in sexual offences in the county or whether this is a trend similar to other areas of UK where there is increased reporting of sexual offences.
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Stakeholder Interviews Integrated Services A Central Organisational Hub and Spoke Model is required with clear integrated pathways. Integrate the Chlamydia Screening programme into the wider community sexual health services. Improve GP communications and integration levels-more shared updated and learning, more opportunities to link up. GPs with a Special Interest (GPwSI), especially those GPs located in the North of Bucks, to be more involved in level 2 outreach being funded via a LES. Introduce a fast tracked referral system between community pharmacists and sexual health services. When SH services are tendered it is important that the service specification ensures that the HIV services remain integrated with other sexual health services with clear referral pathways. Introduce a central single booking system for sexual health appointments. Health Promotion An awareness raising campaign is required for the public, potential and current clients and NHS staff including primary care staff. Increase the use of new technologies in sexual health prevention programs. Children and Young People Sexual health promotion for schools should be better coordinated. HIV education should be introduced from age 8 and generally be included with other illnesses e.g. cancer. Design specialist HIV health promotion and support for children living with HIV. Drop in clinics-that specifically offer targeted advice for young people should be available from accessible locations in Bucks every weekday. RU Safe- Recommend a “Bucks FastTrackMe” card should be introduced and given to children / young people who have been identified as vulnerable so when they make contact with the service they are fast-tracked and offered sufficient time to sort them out at one appointment rather than expecting them to return. The FastTrackMe card-could have RU Safe telephone numbers on the back. Outreach Future services need to utilise experienced sexual health outreach workers to optimise accessing the black African communities and other hard to reach at risk groups. When SH services are tendered it is important to ensure the are some HIV specialist workers who maintain the expertise regarding HIV care in the community benefits and act as a direct link and to other sexual health staff. Outreach prevention and health promotion services should target the MSM and sex workers in Buckinghamshire utilising new technologies. Training Staff training where possible should be integrated with shared CPD updates – to ensure all service providers get to know each other and have a shared understanding of the care pathways. Sexual Health Training and CPD should be promoted via accredited sexual health websites All sexual health staff should be aware of and where appropriate reporting to the Multi-Agency Safeguarding Hub (MASH) (based with the police). The agency is responsible for- children who are missing, SERAC (Sexual Exploitation Risk Assessment Conference), Social services, Police, sexual health, child protection, safeguarding referral, RU Safe, CAMS, Addaction, youth offending service, MARAC domestic violence support etc. Improve the skills of community pharmacists including their contraceptive knowledge.
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Staff Survey Ensure the STI and contraception services become fully integrated and HIV remains fully integrated. Improve communication between Level 2 and Level 3 services. Improve the record-keeping IT systems. Promote a multidisciplinary approach that includes strong links with drug and alcohol services. Promote multidisciplinary training. Improve training for primary care staff and community pharmacists. Improve and expand prevention interventions in colleges and schools. Increase out Reach services and target locations that have poor access to sexual health services. Public Survey Increase opening times especially evenings and weekends. Review location of services especially in relation to at risk and hard to reach groups. Review confidentiality procedures in relation to waiting rooms. Introduce new technologies to promote prevention messages and signposting of services. Improve primary care training to improve their delivery of sexual health services. Patient Satisfaction Surveys Overall, the level of satisfaction across Buckinghamshire was considered as excellent across the majority of indicators for BHT and THT. The following indicators received lower responses (below 90%) and could be considered for improvement: Clinic opening times Time taken to book in at reception Level of privacy and dignity at reception Respect and courtesy shown by reception staff Whether the confidentiality policy was explained to you Cleanliness of the waiting area
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16 Conclusion Greater STI screening coverage and easier access to sexual health services is the key to improving the sexual health of Buckinghamshire’s population. Sexual health services should be geographically accessible with enough booked and walk in appointments and enough out of hours and weekend services. An integrated sexual health service should be adopted at all Hub, spoke and outreach tier levels, with a central administrative system for recording: Patient Records Patient Appointments (Booked and Cancelled) Partner Notification Site Activity Outreach Targets and Levels of Achievement Staff Administration and Training Consistent data should be collected from all sites so that new resources can be targeted at areas with high STI prevalence rates and not just areas with high diagnosis rates (that are a symptom of the introduction of a preventative intervention). Data should routinely be monitored to ensure any trends or anomalies are quickly identified. STI screening and treatment interventions should then be introduced to actively engage with populations that are at high risk of STIs. Outreach initiatives should be introduced that target hard to reach and high risk groups. Prevention and health promotion interventions should then be optimised to maintain low STI rates. The demographic groups most affected by HIV (Black African and MSM) should be targeted for preventative testing (including partner testing) and treatment. Undiagnosed and late diagnosed HIV should be recognised as major issues contributing to the spread of the disease as well as poor health outcomes. A Sexual Health Promotion Strategy should be introduced to provide sexual health information to the Buckinghamshire’s sexually active population and inform all current and future service users of what services are available and how they can be accessed. This Sexual Health Promotion Strategy should be integrated within the overall Buckinghamshire Sexual Health Strategy. The Sexual Health Promotion Strategy should use age and ability appropriate media to target all population demographic groups in Buckinghamshire. Staff from all sexual health services as well as GPs, community pharmacists and community workers should all be offered sexual health training on a regular basis to ensure they have the knowledge and skills to provide a consistently good sexual health service.
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17 Summary Evidence Review Recommendations Due to a lack of high quality studies, recommendations are predominantly based on evidence of a moderate standard. For more detailed information on the evidence reviews please see Appendices 6-8. 17.1 Standards & Guidance KEY RECOMMENDATIONS A good range of up-to-date standards and guidance exists that have important application in the development of all levels of services; commissioners should utilise these in their decision making. 17.2 Services Targeting Young People KEY RECOMMENDATIONS It should be understood that the evidence base for services targeting young people remains limited and draws largely on US studies. It should be recognised that no single, dominant service model targeting young people exists in the UK. School-based sexual health services (SBSHS) are well used by young people and reduce early onset of sexual activity and increase access to advice, information and effective use of contraception. Broad-based, holistic service models for young people’s services are recommended. These should include Medical Practitioner input within a Multi-Professional Team. The opinions of young people should be sought to ensure the development of effective and relevant services. Frequent clinics, after-school clinics, confidentiality, walk-in services and staff attitude, are all indicated as service requirements. It should be noted that large financial outlays are not necessarily required for the establishment of effective sexual health services for young people. At existing facilities, training and awareness of staff regarding being sensitive to, and aware of, the needs of young people is indicated. 17.3 Outreach Models KEY RECOMMENDATIONS Outreach models are effective at screening high-risk groups; both mobile units and virtual web- based initiatives are recommended. 17.4 Partner Notification Activities KEY RECOMMENDATIONS Partner notification programs that include a variety of notification activities to suit different individuals are recommended. Activities may include the utilisation of the Internet, text messaging and self -testing kits.
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17.5 Models of Closer Work with Primary Care KEY RECOMMENDATIONS Successful primary/secondary care integration of sexual health services should focus on a combination of the following elements: joint planning; integrated information communication technology; change management; shared clinical priorities; incentives; population focus; measurement - using data as a quality improvement tool; continuing professional development supporting joint working; patient/community engagement; and, innovation. Clear care pathways should be in place for patients being referred on to GUM clinics. 17.6 Innovative New Technologies for Delivering Sexual Health 17.6.1 Digital Options- General KEY RECOMMENDATIONS It should be understood that new digital media has altered the communication landscape, particularly for youth. These communication platforms should be utilised for engaging youth in sexual health promotion and risk reduction. Online sexual health services are indicated, particularly in reaching hard-to-reach groups. The potential benefits of e-health to patients should be understood as including: privacy and confidentiality, anonymity, improved flexibility/ convenience, better informed. The potential benefits of technology to providers should be recognised as including: reaching hard to reach groups, reduced administrative costs, improved efficacy, marketing sexual health services and products. Policy makers need to enforce ethical information practices and ensure health internet regulation, legislation and law in order to maintain public trust and confidence. 17.6.2 Computer Based Interventions KEY RECOMMENDATIONS Advantages of computer technology-based interventions should be understood as including: low delivery cost, easily replicable, ability to customize/tailor content, flexible dissemination channels, increased patient disclosure, similar and sometimes greater efficacy compared to human-delivered/ face-to-face interventions. Interactive computer-based interventions (ICBI) are recommended as tools for learning about sexual health. They have shown positive effects on perceived susceptibility, self-efficacy, intention and sexual behaviour. Digital media-based interventions for adolescents are recommended. Potential positive outcomes include delayed initiation of sex, psychosocial outcomes and increased knowledge. Web based intervention programs and adherence promotion software are indicated in HIV medication adherence. Web-based cognitive behavioural skills training and adherence motivational enhancement are recommended to reduce sexual risk in MSM. A strong online presence and user-friendly patient portal are both recommended.
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17.6.3 Social Media KEY RECOMMENDATIONS Social media is recommended as a mechanism for information dissemination, health promotion/ education and the promotion of positive behavioural change. Culturally tailored mass media messages delivered consistently over time are recommended as they have the potential to reach a large audience of high-risk adolescents. 17.6.4 The Internet and Sexual Health KEY RECOMMENDATIONS The internet is recommended as a vehicle for sexual health promotion. It offers an interactive, non-discriminate and anonymous platform for sexual health education. Issues identified for people seeking online health information should be recognised as including: access difficulty; information overload; disorganisation; search difficulties; overly technical language; lack of user-friendliness; lack of permanence; lack of peer review or regulation; inaccurate, misleading and dangerous information; and maladaptive behaviour The internet should be recognised as a new risk environment for STIs. 17.6.5 Internet Based Testing KEY RECOMMENDATIONS Online STI testing and risk assessment are recommended. They provide convenience of circumventing clinic visits, the ability to test privately and instantly, decreased anxiety. The proliferation of internet‐based services and the lack of regulation of STI tests should raise concern. They contribute to the burden and psychosocial costs of misdiagnosis for STIs. 17.6.6 Text Messaging/ Email KEY RECOMMENDATIONS Text messaging is recommended as a low cost, popular and convenient medium for sexual health promotion. It should be understood that limited evidence exists on the effectiveness of mobile phone messaging for HIV care. However, there is some evidence that weekly text-messaging may be effective in enhancing HIV medication adherence. 17.6.7 Video KEY RECOMMENDATIONS Youth-friendly HIV educational videos are recommended for improving adolescents HIV knowledge and increasing participation in HIV testing. Video counselling may be considered as an adjunct to risk-reduction efforts in outpatient settings. 17.6.8 Drawbacks/ Challenges of E-Health KEY RECOMMENDATIONS Potential drawbacks and challenges around e-sexual health should be understood and taken into account when commissioning services. These may include assuring quality, accuracy and reliability of information.
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Challenges in engaging target groups due to literacy levels, cultural and language differences, age differences, educational differences, and access to technology. Primarily serving those with greater resources could exacerbate health disparities in population subgroups. 17.7 Older People KEY RECOMMENDATIONS Older individuals should be recognised as one of the fastest growing groups of internet surfers who use the net to engage their sexual identities and experiences. Benefits of e-health for older users should be taken into account when commissioning services, these include: assisting in resolving restricted access to healthcare services that may result from limited physical mobility; providing a medium that avoids ageist discrimination. 17.8 General Trends in Sexual Health Behaviour KEY RECOMMENDATIONS Addressing sexual health behaviours is a vital component of reducing the spread of STIs and unwanted pregnancy. Commissioned services should inform and support patient behaviours that reduce the risk of STI infection for example consistent condom use, reduced number of sexual partners and the avoidance of overlapping sexual relationships. Behaviours identified as increasing the risk of STIs may be used to better identify and target those at risk as well as contribute to content for risk awareness interventions: misuse of alcohol and/ or substances, early onset of sexual activity, unprotected sex and frequent change of and/ or multiple sexual partners. 17.9 Key Risk Groups KEY RECOMMENDATIONS Understanding key risk groups for STI’s and HIV is essential to providing appropriate and effective services. Groups at greatest risk include: Young people (aged 15 – 25) (for STIs); Men who have sex with men (MSM) (for STIs and HIV); People from Black African communities (for HIV); People from Black Caribbean communities (for STIs); Sex workers (for STIs and HIV). Commissioners should understand that it is difficult to quantify the number of vulnerable individuals in Buckinghamshire Interventions for culturally diverse and disadvantaged groups should be rooted in evidence- based practice. Health care professionals should be provided with the tools and information they need to give culturally appropriate and effective care to patients. Clear pathways should be put in place to care for vulnerable and at risk individuals including referrals from primary care to GUM clinics. Sexual health services should develop locally-delivered and culturally-appropriate initiatives to improve care pathways. Recommendations described in the Society of Sexual Health Advisors (SSHA) manual may inform working with specific groups.
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17.9.1 Key Risk Group: Young People (aged 15-25 years) KEY RECOMMENDATIONS Commissioners should recognise that whilst STIs disproportionately affect young people, numerous gaps remain in evidence-based programming for adolescents. Programs should be designed and evaluated with adolescents in mind. Recommended key strategies for preventing the spread of HIV infection among adolescents include: early diagnosis, guideline-based treatment, and partner notification of HIV status. Adolescent-focused HIV care should aim to identify and reduce at-risk behaviour, comorbidities, and partner transmission. Comprehensive behavioural interventions are recommended for reducing risky sexual behaviour and prevent transmission of STIs among adolescents. There is no clear evidence to recommend peer education concerning HIV prevention or adolescent pregnancy prevention for young people. Further work is required to develop HIV testing programs that target younger adolescents; however there is some evidence to suggest that rapid POC HIV tests may be accepted and preferred by youth. The proportion of young men having chlamydia tests is significantly less than the proportion of young women; Chlamydia testing programs should aim to address this disparity. Prevention efforts such as greater STI screening coverage and easier access to sexual health services should be sustained with a particular focus on young people. Bolstering support for adolescents is recommended. Staff training in the provision of more youth-friendly health is recommended.
17.9.2 Key Risk Group: People from Black African Communities KEY RECOMMENDATIONS HIV prevention activities should be geographically targeted towards those areas with the highest rates and particularly at more deprived areas. HIV positive Africans access HIV services at a later stage of disease than non-Africans. Commissioners should address key issues affecting utilization of HIV services for Africans in Britain including: High HIV awareness not translating into perception of individual risk Home country experience and community mobilization influencing HIV awareness, appreciation of risk, and attitudes to health services Institutional barriers to care; these include lack of cultural understanding, lack of open access or community clinics, failure to integrate care with support organizations, and the inability of many General Practitioners to address HIV effectively. Community involvement should include input to ensure there is: better cultural understanding within the health care system; normalization of the HIV testing process; and a clear message on the effectiveness of therapy.
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17.10 Teenage Access to Sexual Health Services KEY RECOMMENDATIONS Young people's pathways to seeking sexual and reproductive health services must be taken into account as well as the specific barriers they face before getting to the services, while receiving services, and after leaving the service delivery sites. It is recommended that young person services are located within the most deprived areas of a community. It should be noted that limited cost effectiveness data exists directly applicable to risk groups and STIs, the provision of interventions in GUM clinics, or data comparing interventions in clinics with community based prevention interventions. 17.11 Victims of Violence/ Sexual Abuse KEY RECOMMENDATIONS Intimate partner violence (IPV) is common among women who attend STD clinics and warrants increased attention. Screening for IPV in health care settings is recommended; however information regarding screening methods and instruments is limited. There is some evidence that in screening for IPV women preferred self-completed approaches over face-to-face questioning; computer-based screening did not increase prevalence; written screens had fewest missing data. Knowing about and acting to diminish IPV is important in the context of avoiding repeat abortions. Child sexual abuse (CSA) is associated with HIV risk behaviours and is more prevalent among women living with HIV. There is some evidence to support culturally and gender-congruent psycho-educational interventions for HIV-positive women with CSA.
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APPENDICES
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18 Appendix 1 - Buckinghamshire Sexual Health Staff Survey 2015 18.1 Distribution The Buckinghamshire Sexual Health Staff Survey was sent to all staff in Buckinghamshire Health Trust, Terrence Higgins Trust and Brook Sexual Health Services. 18.2 Number of staff working from each Sexual Health Site Bucks Health Trust - 41 Terrence Higgins Trust - 12 Brook Clinic - 5 18.3 Sexual Health Staff Survey Results There was a very good response rate of 76% with 44 members of staff out of the total 58 members of staff completing the survey.
There was good representation of staff from all the Sexual Health Clinics; some members of staff work at more than one clinic.
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The majority of staff who the completed the survey were clinical.
The top five key components of a successful health sexual health service were identified as being 1. Confidentiality 2. Integrated Sexual Health Services 3. Evidence-Based Clinical Standards 4. Robust Safeguarding Arrangements 5. Access to Ongoing Training And Development for All Staff
The majority of sexual health staff considered there was sufficient booked appointments available, there was sufficient time allocated for new and follow-up appointments and that the current services were sufficiently flexible to allow complex patients to be managed.
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More than half of the staff (57%) consider there should be more walk-in clinics and the remaining staff (44%) considered additional walk-in clinics were not required.
All members of staff with the exception of one member considered the quality of training they received was either very good or good.
All members of clinical staff considered their training for fitting IUDs, IUSs and implants was either very good or good.
The vast majority of clinical staff considered their STI management training had been very good or good. The only area where four members of staff considered training to only be OK was for HIV training.
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Staff Sexual Health Training was provided to the staff by a large number of different sexual health training providers.
All clinical staff stated they were able to keep up-to-date with their training and competencies.
The vast majority of staff considered that they were supported in receiving appropriate training for their job role (94%). Two members of staff considered their training had not been supported (6%).
All staff understand the importance of collecting data and its use to Public Health England and commissioners.
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Q13. Please list three ways electronic patient records (EPR) could be improved Not applicable to GUM due to confidentiality agreements Less coding IT provider having a better understanding of data requirements of individual commissioners To automatically update physical observations (BP etc.) from notes to physical detail section on Lillie Easier access Joining up level 2 and 3 service so that duplication cannot occur Better IT systems Less repetition Use of a standardized nursing language for documentation of nursing care that support nursing practice We don’t use at the moment, so using it may improve patient experience Access notes to integrate services It needs to be user-friendly Stop repetition on forms We do not use Ability to view more than one page at a time, without having to close the template you are working on A better computer system, Lillie is a bit clunky Less questions Unified data collection system for GUM & Contraception If tick declined for HIV test on notes t to automatically add p1b to shard Would require a computer system in each room or portable tablet Having software that is bespoke Be able to view previous consults during current consult Testing the use of the International Classification for Nursing Practice (ICNP®) in electronic patient records that support nursing practice and its use can improve patient care Easier to text people their results with electronic Integration of sexual health and contraception It should fit within our service and not be "tail wagging the dog" i.e. us having to do things because that is the way the computer wants it done Clinical observation (BMI BP etc.) to automatically update from notes to physical details Records from level 3 on the same Lillie system Up to date computer software (still use windows XP which Microsoft no longer supports) IT security to allow sharing of information on national basis Quick and easy proformas Good training EPR very good, unable to list a 3rd Improved communication with other nurses, health care professionals, and administrators of the institutions in which nurse’s work is a key benefit of using a standardized nursing language. Better for duel service Access from clinic computer It must be fully confidential Spell check on notes Hardware that is up to date
Suggested ways that electronic patient records could be improved 1. Avoid repetition 2. IT systems that integrated Levels 1,2 and 3 3. Ensure a high level of security and confidentiality 4. Standardised easy ways to enter notes including BP BMI
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5. Sufficient numbers of computers 6. Standardisation of data entry 7. Include a spell checking system 8. Ensure good IT training of staff Q14. List three key strengths of local Sexual Health Services in Buckinghamshire Expertise of staff incorporating GUM, contraception and HIV in one place established services have a network of communication that allows for appropriate information sharing Central location Good communication and interaction between existing level 2 and 3 services as local. good connections with all services Integrated sexual Health and Contraception Good communication between GP surgery (Wye Valley) and THT. Flexible Robust level 3 service over two sites. Integrated services Local flexible Accessibility and location of the services amount of appointment Good relationship with GUM and contraception LARC fittings the clients like it and offer good word of mouth to their family and friends Knowledgeable, friendly and committed staff excellent referral care pathways between level 2 and 3 Evidence based Robust Level 3 service good services offered such as IUD/implant fittings efficient friendly and professional service Accessible location Staff have multiple skills which allow them to work in more than 1 role as required by the service. Integrated HIV service which doesn't isolate them as different but supports them within a fully integrated service. availability of under 25 services Access to sexual health clinics over two sites, High Wycombe and Aylesbury. strong referral system to GUM level 3 Communication good level 2 service via Terence Higgins trust and chlamydia screening partnership working individualised Dynamics of the facilities 2 locations Integrated Sexual Health with HIV Multiple sites and services 6 days a week offered High level of training and updates offered (especially Child/adult safe guarding and CSE) website very comprehensive with all services listed Quality Experienced HIV Consultant able to manage difficult fittings (that GPs cannot do) and remove deep implants Ongoing training opportunities
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HIV care is integrated into the GUM service Always reviewing, evolving and prepared to put patient care first. confidential environment Good support for venerable adults and child protection. Multi-agency integrated contraception and sexual health The sexual health network good communication between level 2 and 3 Skills and expertise of the healthcare professionals health/ service promotion Great teenage promotion / integration with other services with Sue Low Multidisciplinary approach Excellent 'sexualhealthbucks' website Wide range of services around the county easy and efficient self-referral for bpas Accessible Dedicated Young Persons clinics service is becoming more integrated with GUM Strengths of Buckinghamshire Sexual Health Services included the following 1. Location of services 2. Flexibility of services 3. Improved integration between the GUM and contraception 4. Good communication between service Levels 5. Evidence-based services 6. Knowledgeable friendly committed staff 7. Sexual health services that are integrated with HIV services 8. Good staff satisfaction 9. Good referral pathways between the different levels of service 10. Good sexual health website 11. Dedicated Young Persons clinics 12. Multidisciplinary approach Q15. List three potential concerns you have regarding local Sexual Health Services in Buckinghamshire Fragmentation of GUM & HIV service Changes will fragment our smooth running service especially with HIV access and services. Clinics not long enough Opening times different each day and different over sites. Maybe confusing for public. Referral pathway to mental health (CAMHS) is poor. It’s very hard to get hold of on duty practitioner and they will not take referrals from us. Commissioning process Funding will be cut resulting in an inadequate service Young people monitorisation and assistance Out of hours services Psychosexual services v low or absent in Bucks- tremendous need for this Not integrated at level 3 They are not properly linked from the Trust intranet
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Not enough integration with patient notes (need to be electronic and shareable between sites) Lack of referrals from community pharmacies providing EHC to sexual health screening services Loss of established expertise if services run by different provider Better computer systems If provider changes destabilisation of services through potential loss of staff Safeguarding will be harder to achieve if service fragmented. Pressure on staffing to meet targets set Not enough community clinics Re organisation causing lack of stability for both service providers and users Nursing programs within the community to cover GP surgeries not offering some services If we became tendered then HIV being fragmented from GUM Division between level 2 and 3 We are small - this worries me in case we are too small to survive Staff being spread too thinly to provide an efficient service GP's lack of awareness of difference between level 2 and 3 service Disruption of service if different provider Better systems for ordering stock items Costs to public purse of tender process Some PGDS not in place Loss of a full time specialist HIV SW Fragmentation of existing outreach services e.g. clinics and health promotion in colleges, works well at present delivered by the same provider Use of appropriate technology to support practice and informatics records keeping Great need for better school education- teenagers just not getting the message re safety and infections Young staff do not seem to be training in the field Staff not being fully integrated into all aspects of Sexual health GPs lack of awareness of SARC To have meetings on a day that all can attend
Concerns regarding local sexual health services in Buckinghamshire included the following 1. Fragmentation of GUM and HIV services if they are commissioned by different providers 2. Opening times of services are variable and may be confusing to the public 3. Lack of out of hours services including early morning, evening and weekends 4. Improved Staff training to ensure that they are fully integrated into all aspects of sexual health 5. Poor referral pathways to mental health services 6. Lack of Psychosexual Services in Buckinghamshire despite demand for this service 7. Computer systems are not linked between the services 8. Primary care lacking knowledge about referral pathways to SARC, Level 2 or Level 3 services 9. Some primary care centres are not offering all the services they are contracted to 10. Sexual Health Education in schools needs to be improved
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Q16. List three ways that you think local sexual health services could be improved in Buckinghamshire More walk in clinics Saturday morning GUM service running alongside contraception More resources to enhance the evolving technology and hence service offered. Longer hours Access to bpas. No local provision. Nearest clinic is Milton Keynes. Better info on mental health services/referrals- lots of self harm/depression in young people Appointments at weekends The nearest provision for bpas is Milton Keynes. Poor provision for women seeking/ needing TOP. More community clinics Outreach clinics Provide more technology with appropriate resources & programs for multidisciplinary record keeping Further integration between GUM and contraception. Integration between level 2 and 3 Offer training (DFSRH) to many more nurses in the trust Upskill staff - create a band 4 position to triage and offer health advice and history taking for fast track (asymptomatic patients) Single booking system for level 2 and 3 , triaging appropriately Tighter links between services provided by bcc and health Extended opening hours if funded Having a scanner to carry out deep implants removals effectively Offer later appointments in the evening or early morning Early morning and later pm clinics Increased presence of sexual health services in smaller community locations Guaranteed provider for a decent period to enable stability of service and strategic planning. Talking about the services to people running the service More community clinics More health promotion Increased health promotion and disease prevention with local programmes Greater sex education in schools by trained nurses /promotion staff Good quality services Sexualhealthbucks' website linking in from the main intranet Fully integrate patient notes initially on paper then electronically for both contraception and sexual health (over all sites) Pharmacy giving info of STI screens when giving out EHC Saturday clinic if funded Having more GUM evening clinics that can suit patients better who are at work Being able to offer pop up clinics Website links to FPA etc. Invest in primary prevention More follow up time Sex & relationships education in schools and colleges Increased capacity for support for PLWHIV Management of a local sexual service web site/blog, to assist service users ‘online', with real time advice given by a local health professional, that will closely monitor the website, could eventually refer to the local sexual services after a ‘triage’, as appropriate, with an appointment booked. This initiative will increase individuals involvement, co- responsabilisation and adherence to the eventual therapeutic regimen, as well as demystifying the access to sexual services Improved or psychosexual counselling - at moment we send to oxford and overstretched service Open access between sexual health services and schools Integrated paper records across contraception and GUM Use level 2 services better for sending people when they cannot get an appointment with us?
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Increased advertising about emergency IUD as a method of emergency contraception More outreach if funded Offer a psychosexual counselling service
Suggestions for how sexual health services could be improved in Bucks included 1. Fully integrated GUM and contraception services 2. A centralised appointment booking service that covers all levels of sexual health services 3. Improved opening times especially early-morning late evening and weekends 4. Improved services for all women requesting TOP access to bpas 5. Improved referral pathways to mental health services 6. Improved integration of Level 2 and Level 3 services 7. Improved locations of community clinic’s clinics rural parts of Buckinghamshire 8. Improve training to ensure all clinical staff are dual trained to offer integrated services 9. Improved sex education in schools offered by well trained staff 10. Improved utilisation of IT to offer online assistance to the public and clients 11. Improved health promotion services that advertise emergency contraception 12. Establishing psychosexual counselling services within Buckinghamshire 13. Purchasing scanning equipment that assists in the removal of deep implants 14. More outreach prevention initiatives
Q17. How would you like to see sexual health promotion change over the next five years? more use of new technology posters at bus stops etc. more info on screens in Dr waiting areas more use of motivational interviewing services co located Earlier intervention and access via schools, and youth access to promote sexual health and avoid future infections. Vaccination for HPV for boys and use of 9 Valent vaccines for all groups from 11 years of age. Universal HIV testing. reduce the stigma to reduce the undiagnosed HIV cohort. More ad campaigns. More LARC availability. (coils and implants.) more integrated services and staff Increased awareness of safe sex and how to keep yourself safe. A more robust and well supported provision for child exploitation, as the prevalence feels like it is upon the increase. Lots more SRE in schools and sent home to parent to empower them to discuss issues with their children. lots more teaching sessions on consent That there would be more work around sex and relationships education in schools and organisations. If parents were to receive input from the work place they are more likely to be happy for their children to receive SRE in the classroom. That there would be a multi-agency approach but better working between organisations using and combining skills to produce a robust and comprehensive service that would focus on prevention, good decision making and navigation to services if needed. Possibly to have better clinics to local politicians, to raise the profile and importance of sexual health More education in schools and colleges 1. Health Informatics Penetrating Nurse Education
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2. Advances in information technology within community settings 3. e-access to young/adults to sexual health services within our community More involvement with schools , our teenagers need better information Better liaison with other services, i.e. RU safe, Brook, Safeguarding maybe something like a Facebook page for young people to access with sexual health advice to become open and work together with schools and young people services. The communication is partially there at present but I feel we should work as one team and pool or strengths and resources. Not too much! My concern is that quite a few of the staff are nearing retirement age and when they go they will take so much experience with them. It needs to be recognised that contraception services in particular have always been run by part timers alongside other roles - this is really important, but if it continues to be a service that is admin heavy as opposed to clinical I for one will not stay in it. I recognise that admin and learning are important but they must be relevant. The team's work with looked after children and other vulnerable groups is vital - it would be a service that should be funded so that we can offer training and outreach work to people who need it, not just those that are willing to pay. Use the CSP to offer GC test as well. The lab does it and the results are disregarded so no extra cost but could pick up GC as well. Less 'confidential' and more 'in your face' advertising - More advertising in press and in media - Advertise on Facebook /google/ internet etc. More schools taking part in C-Card scheme/chlamydia screening programme Walk-in clinics at Minor injury units. More pharmacist training to prescribe EC Fully integrated level 2 and level 3 service booking system. Comprehensive programme of SRE offered to all schools and further education places with approved standard of content. more work on resilience and CSE for all schools, youth clubs etc. Better promotion of clinic services and differences between the Levels of service. Patients don’t understand what the Level means and who offers the most appropriate appointment to meet their need. Work closer with local schools as there is not enough consistent sexual health education. Working more closely with local GPs to promote sexual health perhaps workshops/ study days/open days. Much more targeted education work taking place to prevent poor sexual health occurring
Suggestions regarding how Sexual Health Promotion should changes the next five years 1. Increase number of colleges and schools outreach 2. Increase the number of schools taking part in the C-Card scheme. 3. Utilise new technologies to promote prevention messages 4. Ensure HPV vaccination is available for young boys 5. Improve communications campaigns to promote prevention messages 6. A multiagency approach to promote prevention messages focus more on consent 7. Focus on sexual health prevention messages in schools and involve parents 8. Improve skills of staff to ensure they are competent to care for vulnerable young people 9. Carry out a workforce review and identify how retirement will impact on skill mix and capacity 10. Work more closely with primary care teams and offer constructive training and support to ensure they have the capacity to deliver level 1 and in some cases level 2 services. 11. Delivery of fully integrated Level 1 and Level 2 services 12. Fund prevention programmes that are targeted at vulnerable children
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About half the staff knew how to access educational materials in different languages and formats (54%).78% of staff are able to access interpreting and translation services when required.
People with mental health conditions, learning impairments and victims of sexual assault were considered to require longer appointments. In addition homeless people and people with drug and alcohol misuse problems were also considered to require longer appointments. It was considered that young people under 25 years require specialist clinics in addition some staff considered victims of sexual assault, sex workers, and people with drug and alcohol misuse, also need specialist clinics. The many members of staff of staff considered no specialist services were required for MSM or LGPT. In addition some staff considered the homeless, young people under 25 and sex workers did not require specialist services. Only half of the staff responded to this question.
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Q21. What role do you think the local Buckinghamshire Sexual Health Network should have moving forward? Integrated services Continued provision and access for sexual health screening for population of Buckinghamshire. Health promotion in secondary schools and colleges. To steer the services and develop partnership working Supervisory, and advisory making sure we provide the best most efficient service we can Better communication between schools, SRE and young people’s services as well as level 2 and 3 Meeting collaboratively at workshops, this has been really useful in the past.
Maintaining the excellent website To enable ALL residents in Bucks to have access to sexual health and contraception services between 7am and 10pm Mon-Fri and on 9-3 on Saturdays Important to continue its role, regardless of how the tender arrangements change. Website is invaluable for clients. Coordination of services. A link between all health workers within the service. Information and advice provider within the services. Better premises to integrate services.
Offer more contraception clinics in south bucks In relation to the role that Bucks sexual health network should be moving forward to suggestions included the following. 1. Integrated services 2. Continued provision and access for sexual health screening for population of Buckinghamshire. 3. Health promotion in secondary schools and colleges. 4. Better communication between schools 5. To steer the services and develop partnership working 6. Ensure we provide the best most efficient service we can 7. Meeting collaboratively at workshops, this has been really useful in the past. 8. Maintaining the excellent website 9. Improved opening times 7am and 10pm Mon-Fri and on 9-3 on Saturdays 10. Improved coordination across the service. 11. Improved premises 12. Offer more contraception clinics in South Bucks
Q22. What do you think about the changes to the Sexual Health Commissioning arrangements at National level?
Worried that the HIV service will become isolated from general sexual health and yet we are meant to be making HIV testing, treatment and support less stigmatised and easily accessed. Worried that the levels of service will be inconsistent across the county and always under a constant constraint of concern re ongoing contract negotiations/ cost. Worried in practice a well-integrated service will become more fragmented and less responsive to patient need. Changes that need to be made I am very concerned, as the potential impact to the voluntary sector could be damaging. Really don’t think tendering by private companies who have little experience in what happens in a
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Buckinghamshire Sexual Health Services Needs Assessment sexual health clinic a good idea. I.e. Milton keynes, -- hiv fragmented, staff split and poor morale, poor understanding of service, care of patients compromised Don’t know I find it odd that sexual health does not sit with health but with public health - I suppose I don't really get the interface between health and public health. However I have actually found that many things have improved (e.g. The website) since we were commissioned by PH I don't agree with the privatisation of the NHS Although in bucks we are very lucky with the commissioners, seeing sexual health as a priority, this is not the same in other areas. Concerns where budgets are scarce that sexual health may take a low priority.
Concerns were raised regarding how changes in the sexual health commissioning arrangements at national level could impact on Buckinghamshire Sexual Health Services 1. Fragmentation of the service 2. Damage to the voluntary sector 3. HIV split from other services 4. Sexual health being a low priority 5. Concerns regarding privatisation of the NHS
All staff consider there is good partnership working across Buckinghamshire between NHS England, Local Authorities, CCGs and sexual health providers. However only 14/30 members of staff responded to this question.
71% of staff that responded to a question regarding commissioning sexual health services stated they had not been any specific issues. Only 14 members of staff responded to this question.
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No staff had any issues regarding resource allocation of sexual health services. Only 12 staff responded to this question
Q26. If you had a magic wand to make changes, how would you like to see sexual, reproductive health & HIV services in Buckinghamshire look in 5 years’ time?
Daily evening clinics Fully integrated sexual and reproductive/ contraceptive health service offering point of care testing, all methods of family planning , outpatient and access to inpatient care for GUM screening and treatment. Offered at a couple of major hubs across the county with some outlying peripheral clinics to prove access closer to home. For areas at extreme of the county. More money to look outside the box At the Shaw clinic we are very confined to space. Being tucked away at the back of the hospital makes the clinic more confidential, but I feel that this may also make us harder to find. With my magic wand I would like a purpose built clinic, with good car parking facilities (for staff and patients). Rooms for consultation adjoining rooms for examination. Separate rooms for venepuncture, Counselling, Health advising and for contraception. At present the clinic is too small to effectively run sexual health and contraceptive clinics at the same time. In short bigger premises. Larger budget working smart and providing CSW clinics more clinics/ longer clinics in colleges better links with oasis- get more of their clients to attend clinics A merging between sexual health services and drugs services so there is care and support in a one stop shop. A variety of drug/alcohol specialists and sexual health and contraceptive specialists. Hep C and HIV treatment pathway is too fragmented and not user friendly. Especially so for substance misusers who due to their chaotic lifestyles, cannot attend appointments if they have to travel too far Trust bid winning the tender with THT, so we can build on the excellent care we have been working on over the last few years. To give the bid to another use would throw everything in the air and destroy what is a good service make the clinics more integrated so people can access contraception and GUM at same time, so have more duel trained staff Do more training with GPs One big happy family available to all Up to date computers Maintain paper records for clients but have more space to store them far more nurses trained with the NDFSRH Adverts about the self-referral aspect of CASH displayed in all health areas (GPs, dentists, community pharmacies etc.) - we are too often a client’s last port of call and we could be their first Fully integrated for ALL services to cater for all sexual orientations. 24 hrs a day Fully electronic Lillie records for level 1, 2 and 3, central single booking (electronic) system, triaging appropriately. It would be fantastic to have a team to take services on a bus designed to do all that we do in clinic and reach out to the schools and community. Are
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Staff’s vision about how services could be improved in the future included the following. 1. Fully integrated services 2. Improved funding 3. Improved premises 4. Improved outreach to colleges and schools 5. Merging sexual health and drugs and alcohol services as a one-stop shop 6. Integrated hep C and HIV treatment pathways 7. Additional training with primary care 8. Up-to-date IT systems 9. Improved publicity 10. Mobile services delivered to schools and colleges via a bus Q27. Please share any other issues about Buckinghamshire Sexual Health Services Could local drug services be commissioned to screen for STI? The tendering expectation is making staff anxious Additional concerns included staff being anxious regarding the tendering process and a suggestion regarding whether drug services could be commissioned to screen for STIs.
Only 20/44 members of staff as responded to the demographic questions. Of these 85% were female 90% were aged 30 to 64; five members of staff had some type of disability; 50% were Christian; all staff were from a white background; 65% were heterosexual 10% bisexual, 5% Gay and 20% preferred not to say.
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19 Appendix 2 - Buckinghamshire Sexual Health Public Survey 2015 19.1 Distribution Strategy The Draft Buckinghamshire Sexual Health Public Survey 2015 was designed by PHAST and modified by the commissioners. The survey was advertised to the public by alerting key stakeholders by placing the link on websites and sending a SurveyMonkey link via email; a list of the people and groups altered is listed below. The survey link was also advertised via twitter sites that are also listed. In addition paper copies of the survey were distributed for one to one completed and group completion. Reminders were sent on 2 occasions separated by a 2 week period. 19.1.1 General Public Emails/Circulation for Public The survey web link was sent to the following websites and groups. 1. Survey link was placed on the Bucks SH website which has around 1000 hits per month (no tbc by CM) 2. Survey link was sent to the DAAT lead for dissemination to drug and alcohol services e.g. STARS and SMART 3. Survey link was sent to the LBGT group at BCC 4. Survey link was placed by THT on their MYHIV FORUM for the Bucks area 5. Survey link was put on Squirt for MSM 6. Survey link was sent to the Youth service at BCC for circulation for all youth workers (around 40) 7. Survey link sent out to all professionals on the CSE subcommittee of the Bucks safeguarding board for use with clients where appropriate 8. Survey link sent to all members of the Bucks SH Network e.g. 30 members for use with clients where appropriate 9. Survey link sent to members of the Vulnerable Young People working group a subgroup of the Bucks SH Network (around 8 people)
19.1.2 One to One/group work with clients The survey link and paper surveys were distributed to the following groups. 1. Drug and alcohol service worker for SMART did 1:1 with sex worker clients 2. Youth service e.g. Wycombe4Youth did the survey at a residential with YP over 16+ 3. One to one work with highly vulnerable young people e.g. missing or at high risk of CSE via RU Safe 4. One to one with Oasis clients at drug and alcohol service in HW 5. Work with a group of young people at a local college using an iPad tablet at the SH clinics and as part of health promotion outreach 6. One to one with clients living with HIV Support Manager via local HIV outreach and prevention service
19.1.3 Original Tweets and Number of Followers The following twitter hashtags were tweeted; there were 11 retweets from the PH feed and 3 favourites. 1. BCC PH Twitter – 468 followers 2. Bucks County Council – 7,767 followers 3. Aylesbury Vale CCG – 1,488 followers 4. Chiltern CCG – 2,340 followers 5. AVDC – 3,795 followers 6. Chiltern DC - 1,566 followers
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7. Wycombe DC – 5,216 followers 8. South Bucks DC – 1,159 followers 9. Oasis Partnership – 1,004 followers 10. Bucks Family Information Service – 1,135 followers 11. RU Safe Bucks – 125 followers 12. Young Addaction (sic) – 264 followers 13. BuckyMag – 3,762 followers These twitter sites were retweeted for a Second and Third Time 1. Bucks County Council – 7, 767 followers 2. Individual - 567 followers 3. Individual - 130 followers 4. AVDC – 3,795 followers 5. Healthwatch Bucks – 979 followers
19.2 Results Buckinghamshire Sexual Health Services Public Survey 2015 230 members of the public completed the survey. The majority completed the survey online and 55 members of the public completed a paper survey.
54% of the respondents had used sexual health services in the UK and 49% of respondents had used sexual service health services in Buckinghamshire.
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The majority of respondents rated sexual health services in Buckinghamshire as good or very good. Rating scores for doctor’s surgery included more poor or very poor compared to the other services. Please see the detailed table for specific sites.
The majority were informed about sexual health services by the GP or practice nurse. The sexual health website was also identified by a few respondents. Only a few respondents mentioned school or a school nurse been a source of information.
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Most of the respondents had made an appointment at their doctor’s surgery; drop-in was more likely at SHAW, colleges, Brook, Brookside and community pharmacy.
Most respondents sought the opening times during weekdays were adequate, about half responded evening appointments after 6 PM and weekend appointments were inadequate.
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The majority of respondents considered that the services they received were excellent good or okay. A small number considered they were poor or very poor. The clinic opening times were identified as poor more frequently than any other aspect of the sexual health services. All the comments regarding what clients liked best about sexual health services in Buckinghamshire were complimentary; the most frequent statements were friendly, helpful, non-judgemental staff, confidentiality being respected. The vast majority of comments regarding what clients would like to see improved focused on opening times and location of services.
More digital options More on line options for basic things
Most respondents rated the information regarding sexual health services they had received as very good, good or ok.
In response to the three most important things about sexual health services 92% identified confidentiality improve, 57% identified courtesy and respect shown by the doctoral nurse, 33% identified friendly staff and 24% identified open access to the services.
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In response to how sexual health services could be improved 67% requested improved opening hours in the evening at weekends, 48% requested waiting areas being more discreet, 44% requested more integrated services and 30% identified more services should be available online. Q13. Is there anything else you would like to tell us about sexual health services in Buckinghamshire?
Legend Positive comments Suggestions Concerns
Overall the additional comments were positive. Concerns were raised about lack of services in Buckingham and access to appointments. Suggestions included more condoms than 6 at a time, and improved GP and schools SH services.
New to area-not sure No I have experienced problems trying to get through to make an appointment No The service does everything to make what can be a difficult and embarrassing time manageable. I am grateful for the advice which I have received over the past years. I was asked not to urinate at least 2 hours before the appointment but not reminded to drink fluids to improve blood flow for taking bloods (a contradiction maybe) n/a Collection of more than 6 condoms at one time Should be available in GP practices. no It is important in schools. Like in the previous comment I have yet to use the service so I am unclear as to what needs to be improved. Buckingham does not have any services. It's a huge inconvenience to have to travel to places outside of Buckingham. As I left the clinic, in front of my there were three nurses walking of who I heard the one said to the other: "Oh look another bag" (in an amusing way). For me, I may be misinterpreted it, it was a reference to the white paper bag with medication I received during my appointment. FYI: The nurse who was in charge of my examination/ testing was very discreet and helpful. The
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nurses outside probably didn't think I would hear their conversation. Nothing more I would like to add at this point. It's necessary to have this service. The government are making cut backs that are detrimental to the future of this country. With so many young people being promiscuous i find this survey unnecessary as it should be a questionable subject as to whether this service should remain. I personally love the service truly. I found it really helpful. No. It's been very good when I used it. Brookside was very good really would recommend. I had a meltdown and they really did help me calm down No Great staff and approaches provided by SHAW, THT and Brook services all specialist services. Committed Sexual Health Network well led by the public health team at BCC. Good initiatives for high risk groups e.g. Links between community integrated services and drug and alcohol services. All specialist SH services have done the specialist CSE training and are aware of this important issue. Sensitive abortion service provided by bpas who link well with local contraceptive services.
86% of the respondents lived in Buckinghamshire, of these, 35% lived in Aylesbury fail 28% lived in South Bucks 25% lived In Wycombe District Council Area and 12% lived in Chiltern. Q15. Please state the first half of your postcode MK18 52 HP21 17 HP13 12 HP10 6 HP11 6 HP15 6 HP19 6 (Results for all values over 5)
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173/230 respondents who answered the demographic questions 56% were female 41% were male 2% were transgender and 2% preferred not to say. 24% were aged 16 to 19, 43% were aged 20 to 2923% were aged 30 to 49 4% were aged 50 to 64 and 2% were aged 65 to 74. 13% reported they had a disability. 45% reported they had no religion, 38% stated they were Christian, 2% stated they were Muslim, 2% stated they were Hindu and 1% stated they were Buddhist. 73% were from a white background, 11% were Asian, 10% were from black background, 6% were mixed race, and 1% was from an Arab background. (None of the responses are linked to age group.)
The 4 individuals who were under 16 years who answered the paper questionnaire during a supervised session with an SH trained adult present
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20 Appendix 3 – THT Level 2 - Patient Satisfaction Survey 20.1 Annual Patient Satisfaction Questionnaire 2014 The patient survey is conducted annually by all sexual health services and is a requirement of the service specification. Surveys were distributed in the clinics over a period of 4 weeks in the year commencing April 2013. The findings from the THT Level 2 Service are summarised below. Overall, the level of satisfaction across the county was considered as excellent across the majority indicators. The clinic opening times received lower scores indicating that opening times should be reviewed when planning future services. The cleanliness of the waiting area needs to be reviewed in Buckingham. Buckingham and Wye Valley scored less highly compared to Burnham, Chalfont and Chesham in relation to booking/privacy / dignity/respect /courtesy at reception.
Figure 118. Overall questionnaire responses by area
Buckingham Burnham Chalfont Chesham Valley Wye
1. Clinic opening times 43% 47% 52% 48% 49%
2 Time taken to book in at reception 50% 71% 76% 78% 63%
3 Level of privacy and dignity at reception 67% 81% 81% 83% 67%
4 Respect and courtesy shown by reception staff 76% 91% 90% 93% 73%
5 Cleanliness of the waiting area 51% 91% 83% 97% 73%
1.1% said between 1 and 2 hours 6 How long have you waited to see the nurse? 6.1% said between 30-60 minutes 92.8% less than 30 minutes
7 The doctor/nurse introducing themselves to you 95% 90% 92% 90% 88%
8 Whether the confidentiality policy was explained to you 95% 90% 92% 82% 84%
9 How well you were listened to 95% 92% 96% 91% 86%
10 Your involvement in decisions about your care 97% 91% 92% 89% 88%
11 Your questions being answered well enough 93% 95% 93% 92% 88%
12 How private and confidential your appointment felt? 90% 96% 95% 90% 85%
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13 The respect and courtesy shown by the doctor/nurse? 94% 92% 96% 95% 87%
14 How safe you felt during your appointment? 93% 94% 96% 96% 87%
15 Information you received about the service 93% 90% 94% 87% 82%
16 Information you received about your treatment? 93% 90% 93% 87% 86%
17 How satisfied you were after your visit? 93% 90% 93% 89% 85%
If you are aged under 25 years, how friendly the 18 93% 88% 92% 92% 85% environment felt from your point of view?
Legend Poor Fair Good Excellent
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Summary Annual Patient Satisfaction Questionnaire 2014
Source Terence Higgins Trust 2014
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21 Appendix 4- BHT User Satisfaction Survey – 2013/14 User Satisfaction Survey – Buckinghamshire Healthcare NHS Trust 2013/14 The patient survey is conducted annually by all sexual health services and is a requirement of the service specification. Surveys were distributed in the clinics over a period of 4 weeks in the year commencing April 2013. The findings from the Buckinghamshire Healthcare NHS Trust 2013/14 Services are summarised below.
Total Questionnaires completed across whole service 77
GUM, SHAW 32 42%
GUM, Brookside 25 33%
Contraception, Brookside 17 23%
Contraception, SHAW 3 1%
Contraception, YES
Unknown 0
Did you know what would happen to you in the clinic today? Clinic Yes No Not stated Number % Number % Number % GUM, SHAW 20 62% 9 28% 3 9% GUM, Brookside 17 68% 5 20% 2 8% Contraception, 7 41% 2 12% 4 24% Brookside Contraception, SHAW 0 3 100% Contraception YES TOTALS
Was the clinic easy to find? Clinic Yes No Not stated Number % Number % Number % GUM, SHAW 26 81% 5 15% 1 3% GUM, Brookside 24 96% 1 4% Contraception, 12 70% 0 1 6% Brookside Contraception, SHAW 1 33% 2 66% Contraception YES TOTALS
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Was the time/date convenient to you? Clinic Yes No Not stated Number % Number % Number % GUM, SHAW 27 84% 4 12% 1 3% GUM, Brookside 25 100% Contraception, 10 59% 1 6% 2 12% Brookside Contraception, SHAW 1 33% 1 33% 1 33% Contraception YES TOTALS On what day did you attend?
Clinic
Monday Tuesday Wednesday Thursday Friday Saturday Not stated GUM, SHAW 9 12 8 0 0 1 GUM, Brookside 13 6 1 2 4 Contraception, 8 1 4 Brookside Contraception, SHAW 2 1 Contraception YES TOTALS Was the Reception area welcoming? Clinic Yes No Not stated Number % Number % Number % GUM, SHAW 32 100% GUM, Brookside 25 100% Contraception, Brookside 11 65% 2 12% Contraception, SHAW 3 100% Contraception YES TOTALS
How did you hear about the Clinic?
Clinic Nurse l
GP
inCentre
-
Other
Friend
Poster
Leaflet Service Service
Internet
Information
Schoo
Walk Not stated GUM, SHAW 6 9 1 12 1 3 GUM, Brookside 8 3 8 3 3 3 Contraception, 3 2 3 2 1 1 1 Brookside Contraception, SHAW 2 1 Contraception YES
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What did you think of the following? GUM, SHAW Excellent Good Fair Poor Clinic opening times 10 17 2 2 Time taken to book in at reception 21 10 Level of privacy and dignity at reception 19 10 2 Respect and courtesy shown by reception staff 24 6 2 Cleanliness of the waiting area 20 9 3 TOTALS GUM, Brookside Excellent Good Fair Poor Clinic opening times 10 11 4 Time taken to book in at reception 17 7 1 Level of privacy and dignity at reception 15 5 4 Respect and courtesy shown by reception staff 18 6 1 Cleanliness of the waiting area 18 6 TOTALS Contraception, Brookside Excellent Good Fair Poor Clinic opening times 4 8 1 Time taken to book in at reception 5 8 Level of privacy and dignity at reception 7 5 1 Respect and courtesy shown by reception staff 9 3 1 Cleanliness of the waiting area 7 4 2 TOTALS Contraception, SHAW Excellent Good Fair Poor Clinic opening times 2 1 Time taken to book in at reception 1 2 Level of privacy and dignity at reception 1 2 Respect and courtesy shown by reception staff 2 1 Cleanliness of the waiting area 1 2 TOTALS Contraception, YES – no responses Excellent Good Fair Poor Clinic opening times Time taken to book in at reception Level of privacy and dignity at reception Respect and courtesy shown by reception staff Cleanliness of the waiting area TOTALS How long have you waited to see a Doctor / Nurse today? Less than 30 30-60 Between 1 Over 2 minutes Minutes and 2 hours Hours GUM, SHAW 21 7 GUM, Brookside 16 4 Contraception, Brookside 10 1 1 Contraception, SHAW 2 1 Contraception, YES
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Thinking about your consultation with the doctor / nurse today, how do you rate the following? GUM, SHAW Excellent Good Fair Poor The doctor/nurse introducing themselves to you 26 4 How well you were listened to 27 3 Your involvement in decisions about your care 23 7 Your questions being answered well enough 27 3 How private and confidential your appointment felt 24 6 The respect and courtesy shown by the doctor/nurse 25 5 Information you received about the service 22 6 2 Information you received about your treatment 24 6 How satisfied you were after your visit 25 5 If you are aged under 25 years, how friendly did the 16 4 environment feel from your point of view TOTALS
GUM, Brookside Excellent Good Fair Poor The doctor/nurse introducing themselves to you 19 3 How well you were listened to 17 6 Your involvement in decisions about your care 17 6 Your questions being answered well enough 18 6 How private and confidential your appointment felt 18 5 The respect and courtesy shown by the doctor/nurse 18 5 Information you received about the service 17 5 1 Information you received about your treatment 15 7 1 How satisfied you were after your visit 17 6 If you are aged under 25 years, how friendly did the 11 4 environment feel from your point of view TOTALS
Contraception, Brookside Excellent Good Fair Poor The doctor/nurse introducing themselves to you 10 2 How well you were listened to 9 3 Your involvement in decisions about your care 8 4 Your questions being answered well enough 8 4 How private and confidential your appointment felt 9 3 The respect and courtesy shown by the doctor/nurse 9 3 Information you received about the service 7 4 1 Information you received about your treatment 9 2 1 How satisfied you were after your visit 9 3 If you are aged under 25 years, how friendly did the 5 4 environment feel from your point of view TOTALS
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Contraception, SHAW Excellent Good Fair Poor The doctor/nurse introducing themselves to you 2 1 How well you were listened to 2 1 Your involvement in decisions about your care 2 1 Your questions being answered well enough 2 1 How private and confidential your appointment felt 2 1 The respect and courtesy shown by the doctor/nurse 2 1 Information you received about the service 2 1 Information you received about your treatment 2 1 How satisfied you were after your visit 2 1 If you are aged under 25 years, how friendly did the 1 1 environment feel from your point of view TOTALS
Contraception, YES – no responses Excellent Good Fair Poor The doctor/nurse introducing themselves to you How well you were listened to Your involvement in decisions about your care Your questions being answered well enough How private and confidential your appointment felt The respect and courtesy shown by the doctor/nurse Information you received about the service Information you received about your treatment How satisfied you were after your visit If you are aged under 25 years, how friendly did the environment feel from your point of view TOTALS
How likely are you to recommend our clinic to friends and family if they needed similar care or treatment? Extremely likely Likely Neither likely Unlikely Extremely nor unlikely unlikely GUM, SHAW 25 6 1 GUM, Brookside 14 4 1 Contraception, Brookside 6 4 Contraception, SHAW 2 1 Contraception, YES TOTALS
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Any other comments about this service? GUM, SHAW I often see XXXX the nurse who is amazing. She's so knowledgeable and is able to keep you motivated when you start to lose hope. I don’t think my treatment would have been so successful without her. I feel very excellent service and care received from clinic Excellent I left the clinic with information that gave me confidence in dealing with a situation that had me confused and frightened before my visit. Staff really nice. Maybe make clinic more well-known at entrance to hospital (near the university). They were quick and respectful I always feel comfortable visiting this clinic Nurse was excellent The nurse made me feel really at ease and relaxed, was really non-judgemental and real pleasure to talk to her Very friendly accommodating and thorough Very lovely lady and very helpful GUM, As I had no idea what to expect the ladies looking after me were really brilliant, made Brookside me feel at ease. Thank you. Really helpful advice given. Felt comforted and put at ease in GUM XXXX the nurse was excellent Good Contraception, Felt comforted and put at ease Brookside Pill checks are very good and the resulting wait is not acceptable. Could there just be a dedicated clinician for pill checks. People can indicate this is what they are here for on the check in sheet. Also opening times are not convenient for adults working fulltime. Can more evening slots be added (judging by the Monday night wait it's needed) Very helpful. I’m so glad and thankful that I came. So much friendlier and informative than going to see my GP (Don’t have to wait over a month to see someone either) Thanks Good Contraception, The staff were very welcoming and made me feel very comfortable SHAW Good I have been dealing with the aftermath of sexual assault for almost 2 years on my own - finally now I feel that I don’t have to. Thank you to all involved. Number of patients interested in being part of a user group GUM, SHAW 5 GUM, Brookside 2 Contraception, Brookside 1 Contraception, SHAW Contraception, YES TOTAL 8
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22 Appendix 5 - Sexual Health Services Configuration There are close links between sexual health services commissioned by Local Authorities and those commissioned by other authorities 22.1 Local Authorities Local authorities are responsible for commissioning most sexual health interventions and services as part of their wider public health responsibilities, with costs met from their ring-fenced public health grant. While they will be able to make decisions about provision based on local need, there are also specific legal requirements ensuring the provision of certain services, which are set out in the Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 20134.
Local authorities are well placed to understand all the needs of their population and to provide joined-up services which meet those needs. Some people, particularly people living in deprivation will experience multiple inequalities including poor sexual health alongside other issues such as smoking, alcohol or drug misuse, being overweight or obese and not taking sufficient exercise. Some may also need wider support from other council services, through schools and the broader education system, housing, leisure and family and social care support. The local Joint Strategic Needs Assessment and Joint health and Wellbeing Strategy will help local authorities to make the crucial links between the various services they provide.
22.2 Primary Care GPs are key local providers of sexual health care, including contraception and STI testing and treatment, and diagnosing (or excluding) HIV. While not everyone wants to visit their GP for sexual health care, they are the providers of choice for many patients as they are local and convenient. Most GPs offer standard contraception services as part of their GMS or PMS contracts, commissioned by the NHS England. Local authorities will not be involved in commissioning these services, although it may be useful for them to know about GP provision in their areas, particularly if there are any gaps in provision which may have implications for the services that local authorities provide. Some GP practices have staff, including practice nurses, who have undergone additional training to offer LARC and many also offer chlamydia testing as part of the National chlamydia Screening Programme. This provision used to be arranged through NHS Local Enhanced Service and National Enhanced Service arrangements. The Frequently Asked Questions document notes that local authorities will need to consider how this GP provision (and other primary care provision) feeds into their local service plans, and contract for it directly. 22.3 Community Pharmacies Community pharmacies are a feature of most local communities, and some provide a range of sexual health services, including offering chlamydia testing as part of the NCSP, participation in condom schemes and the provision of emergency contraception. Some community pharmacies are keen to expand their sexual health role, and have taken part in pilots of other services, including the provision of regular oral contraception. Community Pharmacy is commissioned by NHS England under the Pharmacy Contract.
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22.4 Abortion Clinical Commissioning Groups (CCGs) commission abortion, sterilisation and vasectomy services. Abortion services play a key role in reducing the risk of repeat unwanted pregnancy (in 2011 36% of all abortions were repeat procedures). Commissioning Sexual Health services and interventions as well as helping women to improve their overall sexual health. Abortion services can do this by providing access to all methods of contraception including LARC, and provision of STI and HIV testing to identify undiagnosed infections. The national service specification used by CCGs to commission abortion services refers to the importance of providing contraception and other services as well as the abortion procedure. Local Authorities and CCGs should consider working together and with local providers of sexual health and abortion services to ensure that local abortion providers are fully linked into wider sexual health services in their area that that offer services such as contraception. 22.5 HIV Treatment and Care & Sexual Assault Referral Centres NHS England commissions HIV treatment and care, as well as the Sexual Assault Referral Centres (SARCs). There is a very close link between the prevention and treatment of HIV, so it is important that there are seamless care pathways from prevention, to testing to treatment and other services at local level. The purpose of specialised HIV care for adults and children is to manage HIV disease and treatment to reduce morbidity, mortality and reduce the transmission of HIV infection to others. The service includes NHS outpatient and inpatient care provided by multidisciplinary teams overseen by HIV consultant physicians. Service specifications have been developed by the HIV Clinical Reference Group. The specification18 sets out the place of specialised care in the overall HIV pathway. The effectiveness of specialised care depends on other support services being in place, and effectively coordination between services. It is also important to ensure that there are quality pathways established for Sexual Assault Referral Centres in relation to counselling and GUM care.
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23 Appendix 6 - Relevant Commissioning Standards 23.1 Relevant National Standards for Commissioning, Organisation and Delivery of GUM Services A good range of up-to-date standards and guidance exists that have important application in the development of level 2 and 3 services; these are outlined and described below. Square bracketed letter and number codes correspond to the full, tabulated result of the literature search. 23.2 Department of Health Commissioning Sexual Health Services and Interventions: Best Practice Guidance for Local authorities (2013): Best practice guidance on commissioning sexual health services and interventions, including guidance on the legislative requirement to commission open access services for contraception and for the testing and treatment of sexually transmitted infections. [B1]4 Sexual Health Commissioning- Frequently Asked Questions (2013): The Frequently Asked Questions document contains the latest details about key issues such as clinical governance, contracting, prices for services and payments by local authorities to out of area providers who provide services to their residents, which will often happen with open-access services. The Department, Public Health England and the Local Government Association will work together to review the Frequently Asked Questions document frequently to make sure that it contains the latest information, and reflects key emerging issues. [B2]5 Public Health Outcomes Framework 2013-16 (2013): The framework outlines desired outcomes for public health and how they will be measured. [B3]6 A Framework for Sexual Health Improvement in England (2013): This document sets out the evidence base for improving sexual health and reducing inequalities. Individuals, commissioners, sexual health service providers and the voluntary sector all have roles to play; leadership and support will be available from PHE. Everyone needs to work together to achieve our ambition to improve sexual health and make a real difference to people’s lives. [B25]7 Quality criteria for young people friendly health services (2011): The quality criteria cover ten topic areas: accessibility, publicity, confidentiality and consent, environment, staff training, skills, attitudes and values, joined-up working, young people’s involvement in monitoring and evaluation of patient experience, health issues for young people, sexual and reproductive health services, specialist child and adolescent mental health services (CAMHS). [B20]8 23.3 National Institute for Health & Care Excellence (NICE) PH51: Contraceptive services with a focus on young people up to the age of 25 (2014): The 12 recommendations made in this guidance include advice on: How to assess local need and commission comprehensive services; Offering culturally appropriate, confidential, non-judgemental, empathic advice tailored to the needs of the young person; Ensuring young people understand that their personal information and the reason why they are using the service will be kept confidential; Providing contraceptive services after pregnancy and abortion; Encouraging young people to use condoms as well as other forms of contraception; How schools and other education settings can provide contraceptive services. [B5]9 LGB21: NICE advice on HIV Testing (2014): This briefing summarises NICE's recommendations for local authorities and partner organisations on promoting HIV testing. It is particularly relevant to health and wellbeing boards, commissioners of HIV testing services and other organisations involved with delivering sexual health services. [B9]10
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PH34: Increasing the uptake of HIV testing among men who have sex with men (2011): The focus of the guidance is on increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission. The recommendations include advice on: Planning services, including assessing local need and developing a strategy; Promoting HIV testing among men who have sex with men, including outreach schemes and providing rapid point-of-care tests; Offering and recommending an HIV test in primary care, secondary care and specialist sexual health services; Repeat testing; HIV referral pathways [B7]11 PH33: Increasing the uptake of HIV testing among black Africans in England (2011): The focus of the guidance is on increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission. The recommendations include advice on: Community engagement and involvement; Planning services, including assessing local need, developing a strategy and commissioning services in areas of identified need; Promoting HIV testing and reducing barriers to testing among black African communities; Offering and recommending an HIV test; HIV referral pathways [B8]12 PH3: Prevention of sexually transmitted infections and under 18 conceptions. (2007): This guidance is for professionals who are responsible for, or who work in, sexual health services. This includes general practitioners and professionals working in contraceptive services, genitourinary medicine and school clinics. The guideline covers assessment, giving advice, partner notification and service coverage. [B6]13 CG30: NICE guidance on long acting reversible contraception (2005): The NICE clinical guideline on long-acting reversible contraception (LARC) offers best-practice advice for all women of reproductive age who may wish to regulate their fertility using LARC methods. It covers specific issues for the use of these methods during the menarche and before the menopause, and by particular groups, including women who have HIV, learning disabilities or physical disabilities, or are younger than 16 years. [B4]14
23.4 British Association of Sexual Health & HIV (BASHH) Guideline: 2012 BASHH statement on partner notification for sexually transmissible infections (2012): The aim of this Statement is to outline general principles on good PN practice, and to provide a resource for quality improvement activity. [B13]15 UK National Guidelines on safer sex advice. The Clinical Effectiveness Group of BASHH and the British HIV Association (BHIVA) (2012): This guideline provides evidence based guidance on the content of safer sex advice and the format and delivery of brief behaviour change interventions deliverable in GUM clinics. [B12]16 British Association of Sexual Health and HIV: Standards for the Management of Sexually Transmitted Infections (2010): The standards represent 2010 current best practice and are intended for use in all services commissioned by the NHS including those provided by the third and independent sectors. They are also strongly recommended for use in services not commissioned by the NHS. The standards cover all aspects of the management of STIs including the diagnosis and treatment of individuals and the broader public health role of infection control. [B10]17 British Association of Sexual Health and HIV: Recommendations for Core Service Provision in Genitourinary Medicine (2005): This document is intended to offer a concise overview of those elements of the physical and staffing needs for the provision of basic core services in GU Medicine at any site. [B11]18
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23.5 Faculty of Sexual & Reproductive Healthcare (FSRH) A Quality Standard for Contraceptive Services (2014): This Quality Standard sets out the contraceptive care that individuals using services should expect and be entitled to receive. The ultimate goal of the Quality Standard is to help those that commission and provide services work with an individual to ensure the best possible outcomes, maximising the opportunities afforded by health policies across the UK. The Quality Standard will help deliver what good looks like for all those who require contraception. [B15]19 Service Standards for Sexual & Reproductive Health Care (2013): The Standards are recommended for use by all providers commissioned or contracted by the National Health Service (NHS) to provide contraception and sexual infection management and services providing pregnancy planning, pregnancy choices, abortion, community gynaecology, sexual wellbeing and health promotion. [B14]20
23.6 Medical Foundation for AIDS (MEDFASH) Standards for the management of sexually transmitted infections (2014): The British HIV Association (BHIVA), working in partnership with care providers, professional associations, commissioners and people living with HIV, has produced a set of quality standards for the care of people with HIV in the UK. They cover 12 key themes, prioritised as being the most important issues for the care of people with HIV. Derived from the best available evidence, the Standards focus on aspects of care that have particular relevance for delivering equitable high-quality services that secure the best possible outcomes for people with HIV. [B17]21
Recommended standards for sexual health services (2005): The recommended standards are not setting-specific and can be applied wherever sexual health services are provided or sexual health need may be identified. The recommended standards have been developed with the aim of enabling people to have prompt and convenient access to consistent, equitable and high quality sexual healthcare. They describe what people should be able to expect from a sexual health service and will serve as a tool for planning, developing and evaluating local services, as well as for local performance management. [B16]22
23.7 Society of Sexual Health Advisors (SSHA) Society of Sexual Health Advisers Manual (2004): The manual covers recommendations on partner notification, managing sexual infections, counselling in health advisor practice, legal and professional framework, community settings, sexual health promotion, and working with specific groups. [B19]23
23.8 Health Protection Agency (HPA)/ Public Health England Making it Work: A guide to whole system commissioning for sexual and reproductive health and HIV (September 2014): This guide is for commissioners of sexual and reproductive health (SRH) and HIV services in local government, clinical commissioning groups (CCGs) and NHS England. [B26]24 Time to test for HIV: Expanded healthcare and community HIV testing in England. (2011): This report provides the final results from eight projects, in hospital (3), primary care (2) and community (3) settings funded by the Department of Health to examine models of HIV testing in these settings. [B21]25
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23.9 Public Health England (PHE) Leaders’ Briefing: Addressing late HIV diagnosis through screening and testing (2014): This briefing provides Public Health leaders with an overview of HIV screening and testing to address the challenge of late HIV diagnoses. It is accompanied by an evidence summary on the impact and economics of HIV screening and testing. [B22]26 Addressing Late HIV Diagnosis through Screening and Testing: An Evidence Summary (2014): This document summarises the rationale and evidence for increasing HIV screening and testing in order to support public health and sexual health professionals, including Directors of Public Health, elected members, commissioners and providers, to establish and improve HIV screening and testing in Medical and community services. [B23]27 HIV in the United Kingdom: 2013 Report (2013): A summary of UK HIV statistical findings from data to end of December 2012. [B24]28
23.10 National AIDS Trust (NAT) Commissioning HIV Testing Services in England (2013): NAT is the UK's leading charity dedicated to transforming society's response to HIV. This document consists of the appendices to NAT’s practical guide for Commissioners covering: assessing need, reviewing current practice, and commissioning responsibilities. [B25]29
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24 Appendix 7- Key Topics Sexual Health Evidence Review Findings are presented in this chapter under topic headings starting with a summary (green box) followed by the key statements identified in the literature. It is important to take account of the local context when considering how evidence sources may apply to services and populations across Buckinghamshire. Evidence statements should therefore be interpreted and applied with caution. Evidence included in this rapid review originates from a range of studies; some conducted in the UK and others in international ‘western style’ countries (including the USA).
24.1 Services Targeting Young People SUMMARY EVIDENCE STATEMENTS: No single, dominant service model targeting young people exists in the UK; the evidence base for these services remains limited and draws largely on US studies. Evidence suggests that school-based sexual health services (SBSHS) have positive effects. Evidence recommends broad-based, holistic service models for young people’s services. Evidence recommends broad-based services which include Medical Practitioner input within a Multi- Professional team. Appropriate data was not found to support cost-effectiveness modelling. PHAST reviewed Sexual health services for young people, either based in or closely linked to schools: [A3]30. Three broad types of UK sexual health service provision were identified: Staffed by school nurses, offering 'minimal' or 'basic' levels of service. Staffed by a multi-professional team, but not Medical practitioners, offering 'basic' or 'intermediate' levels of service. Staffed by a multi-professional team, including Medical practitioners offering 'intermediate' or 'comprehensive' levels of service. No single, dominant service model targeting young people exists in the UK; the evidence base for these services remains limited and draws largely on US studies.30 School-based sexual health services (SBSHS) are not associated with higher rates of sexual activity among young people or an earlier age of first intercourse. Positive effects are evident in terms of reductions in births to teenage mothers and chlamydial infection rates among young men (evidence primarily from USA). Evidence suggests that broad-based, holistic service models, not restricted to sexual health, offer the strongest basis for protecting young people's privacy and confidentiality, countering perceived stigmatisation, offering the most comprehensive range of products and services, and maximising service uptake. Broad-based services which include Medical practitioner input within a multiprofessional team, meet the stated preferences of both staff and young people most clearly. Partnership-based developments of this kind conform to broad policy principles embodied in the UK Every Child Matters framework and allied policy initiatives. Service models have not been rigorously evaluated in terms of their impact on the key outcomes of conception rates and sexually transmitted infection (STI) rates, in the UK or in other countries. Therefore, appropriate data was not found to support Cost-Effectiveness Modelling.
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24.2 Outreach SUMMARY EVIDENCE STATEMENT: Outreach models are effective at screening high-risk groups; there is evidence to support both mobile units and virtual web-based initiatives. The 'mobile-unit' outreach model contacted a large proportion of Public Sex Environment (PSE) users, specifically men who had greater health needs. The study advocates the adoption of this outreach model where the service operates in situ from a dedicated mobile unit to promote sexual health among PSE users, over traditional PSE-based outreach approaches. [A7]31 SafeFriend is a secure and web-based outreach Chlamydia screening strategy developed to target groups of high-risk young people who are currently hidden to care. SafeFriend is believed to be the first web-based outreach screening strategy which combines chain referral sampling with the delivery of targeted Chlamydia testing to high risk young people within their sexual and social networks. [A8]32 24.3 Partner Notification SUMMARY EVIDENCE STATEMENT: There is evidence to support partner notification programs that include a variety of notification activities that suit different individuals. Activities include the utilisation of the Internet, text messaging and self -testing kits. Practitioner perspective on challenges and opportunities re partner notification for STI’s: [A10]33 Partner notification programme which includes a provider referral service and follow-up of outcomes is an essential aspect of sexually transmitted infection management and control. Partner testing and treatment may be expedited by patient-delivered or postal testing kits, medication or prescriptions and by communication technologies such as internet partner notification and text messaging. Collaboration between partner notification specialists, clinical and non-clinical community workers, managers, and commissioners is necessary to ensure the best use of local resources for partner notification and management. A centralised ‘partner notification bureau’ to manage and coordinate partner notification activities across a community may enhance effectiveness and efficiency.
24.4 Integration of Sexual Health Services with Primary Care SUMMARY EVIDENCE STATEMENTS: Examples of successful primary/secondary care integration of sexual health services focus on a combination of the following elements: joint planning; integrated information communication technology; change management; shared clinical priorities; incentives; population focus; measurement - using data as a quality improvement tool; continuing professional development supporting joint working; patient/community engagement; and, innovation. Patients attending primary care require clear care pathways when referred on to GUM clinics. All examples of successful primary/secondary care integration focused on a combination of some, if not all, of the following ten elements: joint planning; integrated information communication technology; change management; shared clinical priorities; incentives; population focus; measurement - using data as a quality improvement tool; continuing professional development supporting joint working; patient/community engagement; and, innovation. Whilst no one model fits
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24.5 Innovative New Technologies for delivering Sexual Health SUMMARY EVIDENCE STATEMENTS: New digital media (e.g. the Internet, text messaging and social networking sites) have dramatically altered the communication landscape, especially for many key demographic groups for GUM and sexual health services and more generally for young people and younger adults. These communication platforms present new tools for engaging key groups including young people in sexual health promotion and risk reduction. E-sexual health (internet-based) presents new opportunities to provide online sexual health services irrespective of gender, age, sexual orientation and location. The internet is a primary way sexual health services can reach hard-to-reach groups. Potential benefits of e-health to patients include: privacy and confidentiality, anonymity, improved flexibility/ convenience, better informed. Potential benefits of technology to providers include: reaching hard to reach groups, reduced administrative costs, improved efficacy, marketing sexual health services and products. Policy makers need to enforce ethical information practices and ensure health internet regulation, legislation and law in order to maintain public trust and confidence. Defining digital technology [E11]35 Online testing/Internet based STI/STD testing or online screening services Self-service sexual health clinic - e.g. Dean Street Express features a high-tech system that allows patients to log themselves in, before being given a self-test kit and shown to a screening room Home sampling and self-sampling Home testing kits Express testing service Information technology E-health refers to internet-based health care and information delivery and seeks to improve health service locally, regionally and worldwide. [E14]36 As technology becomes an ever present part of our everyday lives and people from all backgrounds and age brackets utilise it regularly it seems only natural that health provision embraces the new way patients wish to access information and manage their health. [E15]37. E-sexual health presents new opportunities to provide online sexual health services irrespective of gender, age, sexual orientation and location. [E14]36
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For healthcare providers, e-health can act as an opportunity to enhance their clients’ sexual health care by facilitating communication with full privacy and confidentiality, reducing administrative costs and improving efficiency and flexibility as well as market sexual health services and products. [E14]36 A primary way sexual health services can open up access and reach notoriously hard-to-reach groups is through the internet. [E15]37 Many key demographic groups utilising sexual health services, including HIV clinics, have grown up surrounded by technology – and the anonymity it offers matters to patients. [E15]37 Patient Experience: The first step in the process of improved patient experience is ensuring the patient is directed to, and then receives, the most appropriate level of care, and is neither waiting for excessive time periods nor passed from pillar to post in the process. One way technology can promote improved service delivery is by ensuring the required service is available at the required location. This can be achieved simply by matching clinician competencies with treatments required during the appointment booking stage. [E15]38 SRH and HIV services are at the cutting edge of new technology in healthcare. Given the relatively young age profile of most sexual health service users, there is great potential to maximise the use of advanced health technologies and social media in service development to deliver outcomes for patients at a lower cost. [B26]39 New digital media e.g. the Internet, text messaging and social networking sites have dramatically altered the communication landscape, especially for youth. These communication platforms present new tools for engaging youth in sexual health promotion and risk reduction. [E22]40 To increase and maintain public trust and confidence in such services, policy makers would need to act by enforcing ethical information practices and ensuring health internet regulation, legislation and law. [E14]36 Research around the impact of digital media-based interventions is emerging and rapidly changing. [E22]40 More data from controlled studies with longer (>1 year) follow-up and measurement of behavioural outcomes will provide a more robust evidence base from which to judge the effectiveness of new digital media in changing adolescent sexual behaviour [E22]40 Technology is rapidly advancing and becoming a cost effective option for intervention delivery particularly for isolated and hard to reach populations, such as people living with HIV/AIDS. [E21]41 24.5.1 Computer Based Interventions SUMMARY EVIDENCE STATEMENTS: Interactive computer-based interventions (ICBI) are effective tools for learning about sexual health; they also show positive effects on perceived susceptibility, self-efficacy, intention and sexual behaviour. Advantages of computer technology-based interventions include: low delivery cost, easily replicable, ability to customize/tailor content, flexible dissemination channels, increased patient disclosure, similar and sometimes greater efficacy compared to human-delivered/ face-to-face interventions. Digital media-based interventions for adolescents have been found to positively impact: delayed initiation of sex, influenced psychosocial outcomes such as condom self-efficacy and abstinence attitudes, increased knowledge of HIV, sexually transmitted infections, or pregnancy. Web based intervention programs and adherence promotion software can be useful for helping patients living with HIV maintain medication adherence.
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Web-based cognitive behavioural skills training and adherence motivational enhancement have been shown to reduce sexual risk in men who have sex with men (MSM). A strong online presence and a user-friendly patient portal can make booking appointments, communication with the clinic and checking results far more appealing to the patient and cost effective to the clinic. Further research is required to better establish how interactive computer-based interventions (ICBI) impact biological outcomes, how interventions might work, and their cost-efficacy. Interventions Compared to minimal interventions, self-help interactive computer-based interventions (ICBIs) for sexual health promotion: [E5]42 Showed significant effects on sexual health knowledge, safer sex self-efficacy, safer-sex intentions and sexual behaviour. Had a greater impact on sexual health knowledge than face-to-face interventions did. Are effective tools for learning about sexual health, and show promising effects on self-efficacy, intention and sexual behaviour. More data are needed to analyse biological outcomes and cost-effectiveness of interactive computer-based interventions (ICBIs). Interactive computer-based interventions (ICBI) are effective tools for learning about sexual health, and they also show positive effects on self-efficacy, intention and sexual behaviour. [E7]43 In comparison with face-to-face sexual health interventions, meta-analysis was only possible for sexual health knowledge, showing that Interactive computer-based interventions (ICBI) were more effective. [E7]43 Knowledge Computer-assisted provision of Emergency Contraception (EC) in urgent care waiting areas was found to increase knowledge of Emergency Contraception in a state where EC had been available without a prescription for 3 years. [E38]44 Patient Portal Having a strong online presence and a user-friendly patient portal can make booking appointments, communication with the clinic and checking results far more appealing to the patient and cost effective to the clinic. [E15]37 Interviewing Regarding disclosure of sexual behaviour, Computer-assisted self-interview (CASI) and Computer- assisted personal interview (CAPI) have been found to generate greater recording of risky behaviour than traditional Pen and paper interview (PAPI). Increased disclosure did not increase STI diagnoses. Safeguards may be needed to ensure that clinicians are prompted to act upon disclosures made during self-interview. [E37]45 Youth Results suggest that computer-based programs may be a cost-effective and easily replicable means of providing teens with basic information and skills necessary to prevent pregnancy, STDs, and HIV. [E35]46 A review of literature regarding the impact of digital media-based interventions on the sexual health knowledge, attitudes, and/or behaviours of adolescents aged 13-24 years found that these interventions have been found to positively impact: delayed initiation of sex, influenced
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24.5.2 Social Media SUMMARY EVIDENCE STATEMENTS: Social media may be an effective mechanism for information dissemination, health promotion/ education and the promotion of positive behavioural changes (such as reduced risky sexual behaviour and increased home-based HIV testing). Culturally tailored mass media messages that are delivered consistently over time have the potential to reach a large audience of high-risk adolescents. Peer leaders can be recruited to conduct health interventions using social networking technologies. The 2013 Department of Health Framework for Sexual Health highlights several opportunities including the use of technology and social media in health promotion/education. [B25]55 Social networking communities are acceptable and effective tools to increase home-based HIV testing among at-risk populations. [E18]56 Study results support that social media may be an effective mechanism for information dissemination and the promotion of positive behavioural changes (reduced risky sexual behaviour). [E24]57 Results suggest that peer leaders can be recruited to conduct health interventions using social networking technologies. [E25]58 Culturally tailored mass media messages that are delivered consistently over time have the potential to reach a large audience of high-risk adolescents, to support changes in HIV-preventive beliefs, and to reduce HIV-associated risk behaviours among older youth. [E27]59 24.5.3 The Internet and Sexual Health SUMMARY EVIDENCE STATEMENTS: The internet is an effective vehicle for sexual health promotion Sexual health is one of the common health topics explored on the internet as people increasingly prefer sexual health education to be interactive, non-discriminate and anonymous. Issues identified for people seeking online health information include: access difficulty; information overload; disorganisation; search difficulties; overly technical language; lack of user-friendliness; lack of permanence; lack of peer review or regulation; inaccurate, misleading and dangerous information; and maladaptive behaviour The internet has been recognised as a new risk environment for STIs for both men and women. The internet is an effective vehicle for sexual health promotion [E13]60 Sexual health is one of the common health topics which both younger and older people explore on the internet and they increasingly prefer sexual health education to be interactive, non-discriminate and anonymous. [E14]36 A number of issues have been identified for people seeking online health information or knowledge, they include: access difficulty; information overload; disorganisation; search difficulties; overly technical language; lack of user-friendliness; lack of permanence; lack of peer review or regulation; inaccurate, misleading and dangerous information; and maladaptive behaviour. [E14]36 The internet has been recognised as a new risk environment for STIs for both men and women [E13]60
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24.5.4 Internet Based Testing SUMMARY EVIDENCE STATEMENTS: Online STI testing and risk assessment can provide convenience of circumventing clinic visits, the ability to test privately and instantly, increased privacy and decreased anxiety. The proliferation of internet‐based services and the lack of regulation of STI tests should raise concern as they contribute to the burden and psychosocial costs of misdiagnosis for STIs. Although it is important for individuals to take responsibility for their own sexual and reproductive health, the proliferation of internet‐based services and the lack of regulation of STI tests should raise concern. These STI services are offering testing to those who are reluctant to access public‐sector services because of the stigma associated with STI. The burden and psychosocial costs of misdiagnosis for STIs should be taken seriously. [E13]60 Online STI testing and risk assessment can provide convenience of circumventing clinic visits, the ability to test privately and instantly, increased privacy and decreased anxiety. [E14]36 24.5.5 Text Messaging/ Email SUMMARY EVIDENCE STATEMENTS: Text messaging is a low cost, popular and convenient medium for sexual health promotion. Text messaging to young people has been found to significantly increase knowledge on sexual health and STI testing. Limited evidence exists on the effectiveness of mobile phone messaging for HIV care. Weekly text-messaging has been found to be efficacious in enhancing adherence to antiretroviral therapy and improving HIV viral load suppression. Text messaging to young people significantly increased their knowledge on sexual health and STI testing. [E14]36 Text messaging and email were found to be low cost, popular and convenient mediums for sexual health promotion [E14]36 SMS programs may be useful to reduce risk for sexually transmitted diseases among at-risk young adults being discharged from the ED. Future trials should examine ways to improve adherence to SMS dialog over time and measure objective outcomes in a larger sample. [E19]61 The results demonstrate that using two-way text messaging to dynamically tailor adherence messages may enhance adherence and improve important clinical outcomes for PLWH. [E20]62 24.5.6 HIV Technology based interventions are used for people living with HIV, for example medication adherence delivered via SMS/text messaging, mobile phones and computers. A review identified several gaps in the literature particularly the lack of technology-based interventions focusing on engagement and retention to care as well as sexual risk reduction. [E21]63 Limited evidence exists on the effectiveness of mobile phone messaging for HIV care. [E39]64 However there is high-quality evidence that mobile phone text-messaging at weekly intervals is efficacious in enhancing adherence to ART, compared to standard care. [E23]65 Policy-makers should consider funding programs proposing to provide weekly mobile phone text- messaging as a means for promoting adherence to antiretroviral therapy. Clinics and hospitals should consider implementing such programs. [E23]65
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There is high quality evidence from one trial that weekly mobile phone text-messaging is efficacious in improving HIV viral load suppression. [E23]65 24.5.7 Video SUMMARY EVIDENCE STATEMENTS: Youth-friendly HIV educational videos have been shown to improve adolescents HIV knowledge and increase participation in HIV testing more than in-person counselling. Video Doctor counselling is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention. Reducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Positive Choice, including Video Doctor counselling, is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention. [E33]66 A young people friendly HIV educational video improved adolescents' HIV knowledge and increased their participation in HIV testing more than in-person counselling. Video based HIV counselling can perform as well or better than in-person counselling for young people in the ED. [E28]67 24.5.8 Drawbacks/ Challenges of E-Health SUMMARY EVIDENCE STATEMENTS: Potential drawbacks and challenges around e-sexual health include difficulty in engaging target groups, eliminating health disparities, communication inequalities and assuring quality, accuracy and reliability of information. Online sexual health services may face challenges in engaging target groups due to literacy levels, cultural and language differences, age differences, educational differences, and access to technology. Primarily serving those with greater resources could exacerbate health disparities in population subgroups. The potential drawbacks around e-sexual health include difficulty in engaging target groups, eliminating health disparities, communication inequalities and assuring quality of information. [E14]36 The greatest challenge for e-sexual health may be accuracy and reliability of information. [E14]36 Online sexual health services may face challenges in engaging target groups by meeting the broad range of sexual health needs due to literacy levels, cultural and language differences, age differences, educational differences, and access to technology. [E14]36 E-health has significant challenges in eliminating health disparities. Sexual health related services in e-health could primarily serve those with greater resources (i.e., better resourced and integrated health care systems and infrastructure), which can exacerbate health disparities in population subgroups [E14]36 24.5.9 Accessing E-Health SUMMARY EVIDENCE STATEMENTS: E-sexual health services can be of benefit to rural and/or remote populations The internet is a medium that never closes allowing consumers to gain access to websites on sexual health whenever and wherever they want.
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The adoption of e-sexual health services can be of benefit to rural and/or remote populations. [E14]36 Considering that the internet offers services to its consumers at any time of the day, it is a medium that never closes allowing consumers to gain access to websites on sexual health whenever and wherever they want [E14]36 24.5.10 Older People SUMMARY EVIDENCE STATEMENTS: Older individuals also seek information online and are one of the fastest growing groups of internet surfers who use the net to engage their sexual identities and experiences. For older people who have access to the internet, e-health may assist in resolving restricted access to healthcare services that may result from limited physical mobility The internet provides a medium that avoids ageist discrimination. Research studies consistently report that older individuals also seek information online and are one of the fastest growing groups of internet surfers who use the net to engage their sexual identities and experiences. [E14]36 For older people who have access to the internet, e-health may assist in resolving restricted access to healthcare services that may result from limited physical mobility. [E14]36 This medium also provides a means to avoid discrimination based on physical appearance, such as wrinkles, grey hair, skin colour, and body size, and the initial prejudices older people might otherwise encounter with health professionals, peers or other community members. [E14]36
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25 Appendix 8 – Evidence Review -Trends in Sexual Health Behaviour This section is based on the evidence review results and not from the most recent data. The section includes Key Risk & Inequalities Groups 25.1 Trends in Sexually Transmitted Infections SUMMARY EVIDENCE STATEMENT: Sexually transmitted infections (STIs) represent an important public health problem. Men have much higher rates of acute STIs than women. Chlamydia is the most common bacterial sexually transmitted infection, with sexually active young people at highest risk. Gonorrhoea poses a significant and increasing public health challenge due to the ability of the bacteria that cause it to rapidly develop resistance to antibiotics. Most gonorrhoea diagnoses are made in GUM settings however gonorrhoea diagnoses made in non-GUM settings should be referred to a GUM clinic for confirmation, treatment and partner notification. Rates of infectious syphilis are at their highest since the 1950s. Men have much higher rates of acute STIs than women. [C27] The numbers of new diagnoses of STIs in England rose by 2% in 2011. [C28]68 The number of STIs diagnosed in GUM patients declined between 2004/05 and 2009. [C1]69 Chlamydia is the most common bacterial sexually transmitted infection, with sexually active young people at highest risk. [B1]4 Gonorrhoea poses a significant and increasing public health challenge due to the ability of the bacteria that cause it to rapidly develop resistance to antibiotics. [C27] [C28]68 [B25]7 Most gonorrhoea diagnoses are made in GUM settings as shown by recent evidence (97% in men and 87% in women). [D17]70 [D6]71 The British Association for Sexual Health and HIV and Health Protection Agency (HPA) recommend that all gonorrhoea diagnoses made in non-GUM settings are referred for confirmation, treatment and partner notification to a GUM clinic. [D18]72 Rates of infectious syphilis are at their highest since the 1950s [B25]7 The number of new diagnoses of syphilis increased by 10% in 2011. [C28]68 25.2 Key Risk Group: Young People (aged 15-25 years) SUMMARY EVIDENCE STATEMENT: STIs disproportionately affect young people. Key strategies for preventing the spread of HIV infection among adolescents include: early diagnosis, guideline-based treatment, and partner notification of HIV status. Comprehensive behavioural interventions reduce risky sexual behaviour and prevent transmission of STIs among adolescents. There is no clear evidence of the effectiveness of peer education concerning HIV prevention for young people
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Young people accept and prefer rapid POC HIV tests when offered. Further work is needed to develop HIV testing programs that target younger adolescents. There is no clear evidence of the effectiveness of peer education concerning adolescent pregnancy prevention for young people. The proportion of young men having chlamydia tests is significantly less than the proportion of young women. Numerous gaps remain in evidence-based programming for adolescents. Many programs are not explicitly designed or evaluated with adolescents in mind. Prevention efforts such as greater STI screening coverage and easier access to sexual health services should be sustained with a particular focus on young people. Evidence reinforces bolstering support for adolescents. Training staff to provide more youth-friendly health services can increase the utilization of health services for suspected STIs by young people. STIs disproportionately affect young people [C28]68 Sexually active young people in developed countries have an increased risk of acquiring STIs. [C59]73 25.2.1 Teenage Pregnancy England has one of the highest rates of teenage pregnancy in Western Europe, although rates have reduced significantly of the past decade5.74 When compared to standard practice or no intervention, there is no clear evidence of the effectiveness of peer education concerning adolescent pregnancy prevention for young people in the member countries of the European Union. [C50] 25.2.2 Chlamydia in Young People Chlamydia diagnoses (15-24 year olds) - Since 2000, substantial increases have been noted in attendance at sexual health clinics (from 6·7% to 21·4% in women and from 7·7% to 19·6% in men).The proportion of young men who had a chlamydia test in the past year is less than two-thirds the proportion of young women (37% vs. 57%) [B26]24 Many programs are not explicitly designed or evaluated with young people in mind. [C39]75 Numerous gaps remain in evidence-based programming for young people. [C39]75 Evidence reinforces bolstering critical areas such as education, services, and support for young people. [C39]75 Training staff to provide more youth-friendly health services can increase the utilization of health services for suspected STIs by young people, especially among young men. [C56]76 25.3 Key Risk Group: People from Black African Communities SUMMARY EVIDENCE STATEMENTS: Black Africans remain a key risk group for HIV, after MSM HIV is most prevalent among women and men from black-African communities. Almost a quarter of black-African men and women living with HIV are unaware of their status. HIV prevention activity should be geographically targeted towards those areas with the highest rates and particularly to the most deprived areas.
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In the UK HIV positive Africans access HIV services at a later stage of disease than non-Africans. Key issues affecting utilization of HIV services for Africans in Britain include: High HIV awareness not translating into perception of individual risk Home country experience and community mobilization influencing HIV awareness, appreciation of risk, and attitudes to health services Institutional barriers to care; these include lack of cultural understanding, lack of open access or community clinics, failure to integrate care with support organizations, and the inability of many General Practitioners to address HIV effectively. Community involvement should include input to ensure there is: better cultural understanding within the health care system; normalization of the HIV testing process; and a clear message on the effectiveness of therapy.
25.3.1 HIV & Black Africans African populations are a group at greater risk of contracting HIV. [B1]4 Black Africans remain a key risk group for HIV. In the UK, after MSM HIV is most prevalent among women and men from black-African communities with 38 per 1,000 living with the infection (26 per 1,000 in men and 51 per 1,000 in women)). [B9]10 [C29] Of the 31,800 (29,700-34,600) black-African men and women living with HIV, 23% remained unaware of their infection in 2012. [C29] Over the past five years, an estimated 1,000 black-African men and women probably acquired HIV in the UK annually. [C29] 25.3.2 Access to HIV Services for Africans in Britain In the UK HIV positive Africans access HIV services at a later stage of disease than non-Africans. [C70]77 A 2012 study among male GUM attendees found differences in GUM clinic access by ethnicity and gender; black African men were more often referred by their GP. [D12]78 Key issues affecting utilization of HIV services for Africans in Britain include: [C70]77 High HIV awareness not translating into perception of individual risk Home country experience and community mobilization influencing HIV awareness, appreciation of risk, and attitudes to health services Institutional barriers to care; these include lack of cultural understanding, lack of open access or community clinics, failure to integrate care with support organizations, and the inability of many General Practitioners to address HIV effectively. Community involvement should include input to ensure there is: better cultural understanding within the health care system; normalization of the HIV testing process; and a clear message on the effectiveness of therapy.
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25.4 Teenage Access to Sexual Health Services SUMMARY EVIDENCE STATEMENTS: Access to services is a central concern surrounding the promotion of sexual and reproductive health and rights (SRHR) of young people. Young people may face several barriers to accessing reliable, useful, and age-appropriate information and services for their health. Females aged 17 and under may be more likely to use a young people's sexual health service than mainstream services. Young people's pathways to seeking sexual and reproductive health services must be taken into account as well as the specific barriers they face before getting to the services, while receiving services, and after leaving the service delivery sites. Service type and socio-economic status impact upon the choices young people make when accessing community sexual health services. Evidence supports locating young person services within the most deprived areas of a community. Access to services is a central concern surrounding the promotion of sexual and reproductive health and rights (SRHR) of young people. [C14]79 Young people may face several barriers to accessing reliable, useful, and age-appropriate information and services for their health. [C13]80 No significant differences in accessibility of services between teenage girls who have conceived and those seeking sexual health services were found. [D2]81 Females aged 17 and under may be more likely to use a young people's sexual health service than mainstream services. [D2]81 A young person living in the most deprived quintiles was more likely to use a mainstream service if it was closer to their home address. [D2]81 Analysis shows how personal the whole process, from accessing sexual and reproductive health services to the end of the visit, is for the young person (age 10-25 years). Concluding that to make sexual and reproductive health services more appealing to young people these barriers to services need to be recognised and reduced. [C8]82 Service type and socio-economic status impact upon the choices young people make when accessing community sexual health services. The study supports policy for locating young person services within the most deprived areas of a community. [D2]81 Young people's pathways to seeking sexual and reproductive health services must be taken into account; and the specific barriers they face before getting to the services, while receiving services, and after leaving the service delivery sites. [C14]79
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25.5 HIV prevention interventions that specifically target African communities HIV Testing
There is evidence to support routine offering of HIV tests to migrant and minority ethnic inpatients, outpatients and those attending GUM clinics to increase the uptake of HIV testing. [HIV-A9]
There is evidence to support the use of rapid HIV testing in clinical settings to increase the uptake of HIV testing. [HIV-A9]
There is evidence to support offering anonymous HIV testing to encourage earlier testing. [HIV-A9]
There is evidence to support simplifying referral pathways to GUM clinics, to encourage earlier HIV testing and fewer late diagnoses. [HIV-A9]
There is evidence to support confidentiality at clinics or community-based HIV testing services. [HIV-A9]
There is evidence to support mobilising African community members to advocate about HIV testing through outreach and education programmes to improve HIV testing. [HIV-A9]
There is some evidence that increasing the awareness of the benefits of earlier diagnosis and access to HIV medication might increase HIV testing amongst African communities. [HIV-A9]
There is evidence that finding, testing and treating people from African communities with HIV is likely to be cost effective. [HIV-A9] Addressing Barriers to Testing
There is evidence that low visibility of HIV and lack of positive imagery increase HIV related stigma within African communities. [HIV-A9]
There is evidence that people in African communities experience reluctance to undergo HIV testing because fear of racism and prejudice from outside African communities. Fear of isolation and social exclusion following HIV diagnosis are also a barrier to HIV testing among African communities. [HIV-A9]
There is evidence that preventive, health-seeking behaviour (that is, accessing HIV testing when well) is seen an unfamiliar concept to African communities in England. [HIV-A9]
There is evidence that reliance on oral traditions in African societies makes it difficult for migrant Africans in England to obtain appropriate information about HIV testing. [HIV-A9]
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There is evidence that complicated pathways to genitourinary medicine clinics (e.g. multiple referrals from GPs), delays HIV testing and results in late diagnosis for individuals from African communities. [HIV-A9]
There is evidence that HIV testing in sexual health clinics is seen as stigmatising, complicated and time consuming by African communities. [HIV-A9]
There is evidence that mobilising African community members to advocate about HIV testing through outreach and education programmes can improve HIV testing. [HIV-A9]
There is evidence that HIV prevention and testing messages that target African people only are perceived as problematic and stigmatising. [HIV-A9]
Interventions
There is evidence to support the use of behavioural interventions and community- level and group-level interventions, to reduce sexual risk-taking behaviour. [HIV-A16]
There is evidence that behaviour change interventions are effective at reducing HIV risk behaviours among black MSM, however such interventions alone are unlikely to have a population level effect on HIV infection among black MSM. [HIV-C19]
There is evidence to support the use of sexual health improvement programmes that include: having a peer education element; aiming to influence social norms about safer sex and condom use; containing skills training and practice time; including negotiations skills and role play; providing multiple opportunities to reinforce learning and skills; and programmes that are culturally tailored. [HIV-A16]
There is evidence to support the use of sexual risk reduction interventions with intensive interpersonal skills training to reduce numbers of sexual partners, particularly amongst younger participants. [HIV-A23]
There is evidence to support the use of brief sexual risk reduction interventions (e.g. 15 minutes) for short-term change outcomes; and multiple-session interventions for long-term behaviour maintenance. [HIV-A23]
There is evidence to support the use of voluntary counselling and testing, including working in culturally acceptable ways to promote safer sex and knowledge of available sexual health services. [HIV-A26]
There is limited evidence to support the use of sexual risk reduction interventions to increased condom, including providing intensive and extensive content with interpersonal skills training across multiple sessions for MSM and people already infected with HIV. [HIV-A23]
There is evidence to support focusing HIV prevention interventions on: young people, heterosexual African men, and African MSM. [HIV-A26]
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There is limited evidence to support encouraging primary care practitioners to distribute HIV prevention materials and carry out HIV testing for African communities. [HIV-A26]
There is limited evidence to support the use of interventions that involve community-based organisations and informal African networks. [HIV-A26]
There is evidence to support the use of interventions that encourage gaining or returning to employment as well as dealing with HIV stigma in the workplace to reduce underlying issues of poverty. [HIV-A26]
Evidence does not support HIV prevention and testing messages that target African people only. [HIV-A9]
25.6 Victims of Violence/ Sexual Abuse SUMMARY EVIDENCE STATEMENTS: Sexual assault, coercion, lack of power to negotiate sexual relations and inability to insist on intercourse-related methods of contraception, such as condoms, have been well documented as violations of women's sexual and reproductive self-determination. Intimate partner violence (IPV) is associated with a wide range of negative outcomes, including sexual risk behaviour. IPV is common among women who attend STD clinics and warrants increased attention. Screening for IPV in health care settings is recommended by some professional organizations; however information regarding screening methods and instruments is limited. In screening for IPV women preferred self-completed approaches over face-to-face questioning; computer-based screening did not increase prevalence; written screens had fewest missing data. Research is needed to better understand the pathways linking IPV and HIV risk in women to optimize the design of effective interventions. Organisations act to protect the legality of abortions performed at later gestations is to support victims of domestic violence who present late. Knowing about and acting to diminish IPV is important in the context of avoiding repeat abortions. Child sexual abuse (CSA) is associated with HIV risk behaviours and is more prevalent among women living with HIV. Findings support culturally and gender-congruent psycho-educational interventions for HIV-positive women with CSA. Sexual assault, coercion, lack of power to negotiate sexual relations and inability to insist on intercourse-related methods of contraception, such as condoms, have been well documented as violations of women's sexual and reproductive self-determination. [I1]83 Estimates from the Crime Survey for England and Wales indicate that there are around 400,000 female victims of sexual offences each year and, of these, around 85,000 are victims of the most serious offences of rape or sexual assault by penetration [B25]7
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Intimate partner violence (IPV) is associated with a wide range of negative outcomes, including sexual risk behaviour. Intimate partner violence (IPV) is common among women who attend STD clinics and warrants increased attention. [C66]84 25.6.1 Screening For Abuse/Violence Screening for intimate partner violence (IPV) in health care settings is recommended by some professional organizations, although there is limited information regarding the accuracy, acceptability, and completeness of different screening methods and instruments. In screening for intimate partner violence (IPV), women preferred self-completed approaches over face-to-face questioning; computer-based screening did not increase prevalence; and written screens had fewest missing data. These are important considerations for both clinical and research efforts in IPV screening. [C69]85 25.6.2 Abuse/ Violence & HIV Child sexual abuse (CSA) is associated with HIV risk behaviours and more prevalent among women living with HIV than in the general population. Study findings provide initial support for a culturally and gender-congruent psycho-educational intervention for HIV-positive women with child sexual abuse. [C65]86 Research is needed to better understand the pathways linking Intimate partner violence (IPV) and HIV risk in women, to optimize the design of effective interventions. [C66]84 25.6.3 Abortion Following Abuse/Violence One of the reasons that healthcare organisations such as the Royal College of Obstetricians and Gynaecologists act to protect the legality of abortions performed at later gestations is to support victims of domestic violence who may present late. Knowing about and acting to diminish intimate partner violence is important, particularly in the context of avoiding repeat abortions. [I1]83
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26 Appendix 9 - Evidence Review Methodology 26.1 Methodology The evidence review process is systematic and clearly documented, but does not represent the standards of a full systematic review. Due to the broad scope and finite resources available the reviews are rapid reviews. This means that whilst each review aims to identify the most important and relevant messages that are well supported by the scientific literature; the findings do not extend to: all interventions and outcomes; nuances for different populations and contexts; or areas where the evidence is inconclusive. The rapid evidence reviews focus on delivering a summary of clear and concise evidence statements based on recent and relevant evidence publications. The reviews aim to provide commissioners with a robust basis for decision making and directing needs assessments based on the evidence that is well accepted across the scientific community.
Rapid Review Stages Key stages of the rapid review process include: Review of inclusion criteria. Identifying search terms for the review. Reviewing NICE guidance for included conditions/topics/fields. Undertaking an evidence review using search terms and use of search filters Completing the results section, based on the key evidence statements for each priority area. Use the results section systematic reviews/meta-analysis evidence statement summarises to form KEY RECOMMENDATIONS that are prioritised to inform commissioning decisions. The review searched the following databases: PubMed; NHS Evidence; Cochrane Library; AMED; CINAHL; HMIC; Embase; Medline; PsycINFO. Where appropriate the grey literature regarding recent studies was reviewed. The rapid reviews consist of identifying 5 publications for each rapid review. The rapid reviews adhere to the following evidence identification process: Review of systematic reviews and meta-analyses to identify the highest evidence, most relevant publications. Where this evidence does not exist randomised controlled trial evidence has been identified where possible. Where gaps are identified in the coverage of priority areas by systematic reviews, meta-analyses and randomised controlled trials search criteria have been widened to other published sources and grey literature. Such sources identify the most relevant matches to the ‘search terms’ for the priority area. It should be noted from the outset that interventions based on such evidence are less robustly supported by the scientific literature than those identified through systematic reviews. International literature has been included where it is relevant and generalisable i.e. largely this is research conducted in ‘Western-style’ countries and not from developing countries. Evidence searched only includes literature published in the last 10 years. The evidence searched is based on agreed inclusion criteria and search strategies. Commentary is provided on the quality and relevance of the evidence.
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27 Appendix 10 - Reducing Unintended Conceptions 2015 This is an internal Buckinghamshire County Council Paper produced for the Director of Public Health 2015. Evidence summary - compiled by Angie Blackmore BA (Hons), MSc, UKPHR FR0631, Public Health Principal, Buckinghamshire County Council, and Dr Ravi Balakrishnan MD FFPH, Consultant in Public Health Medicine, Buckinghamshire County Council
27.1 Evidence base One to one intervention with young people at risk could reduce rates of STIs and unintended conceptions (NICE 2007).[1] Evidence shows that substantial investment in improving contraceptive services paralleled with the significant fall in the teenage conceptions rates during that period (2008-10).[2] Long acting reversible (LARC) methods of contraception were more effective in tackling unintended pregnancies than condoms OR pills and greater use of LARC methods could result in cost savings (NICE, 2005)[3] Nationally, new STI diagnosis rose by 5% in 2012 and any restriction of sexual health services (especially prevention) could lead to further increase in new infections. The average abortion rates are higher in areas where services are restricted compared to areas with no restrictions. Early diagnosis and early access to HIV treatment reduces the individual’s viral load which contributes to reducing onward transmission and the number of new HIV cases.[4] Increasing the effectiveness of partner notification is likely to cost less than increasing male coverage but also improve the ratio of women to men diagnosed[5] The level of benefit of chlamydia screening depends in part on how chlamydia screening is implemented. The NCSP recommends that chlamydia screening should be commissioned in conjunction with a range of sexual and reproductive health services and local commissioners to use their data to ensure that resources are deployed in services which provide a 5% to 12% positivity rate.[6] A recent report "Unprotected Nation" by Lucas S (2013) identified the financial and economic impacts of restricted contraception and sexual health services exploring not only NHS, but wider public health sector costs such as welfare, social care which would be significant if services were restricted
[1] One to one interventions to reduce the transmission of sexually transmitted infections and to reduce the rate of u8nder 18 conceptions, especially among vulnerable and at risk groups (PH3) ; National Institute of Health and Clinical Excellence, 2007 [2] Conceptions Statistics in England and Wales 2010 ; Office for National Statistics, February 2012 [3] Long-acting reversible contraception; the effective and appropriate use of long-acting reversible contraception (CG30) ; National Institute of Health and Clinical Excellence, October 2005 [4] UK Guideline for the use of post-exposure prophylaxis following sexual exposure ; British Association of Sexual Health and HIV, 2011 [5] http://www.bmj.com/content/342/bmj.c7250 [6]http://www.chlamydiascreening.nhs.uk/ps/resources/evidence/Opportunistic%20Chlamydia%20Screening_Evidence%20Summary_April %202014.pdf
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Sources: Long-acting reversible contraception; the effective and appropriate use of long-acting reversible contraception (CG30) ; National Institute of Health and Clinical Excellence, October 2005 [1] UK Guideline for the use of post-exposure prophylaxis following sexual exposure ; British Association of Sexual Health and HIV, 2011 [1] http://www.bmj.com/content/342/bmj.c7250 [1]http://www.chlamydiascreening.nhs.uk/ps/resources/evidence/Opportunistic%20Chlamydia%20Sc reening_Evidence%20Summary_April%202014.pdf
27.2 How do we know it is cost effective?
Value for money Every £1 invested in contraception saves £12.50[7] Every £1 spent preventing teenage pregnancy £11 in healthcare cost [8]. Contraception is cost effective, saving the NHS £11 for every £1 invested in addition to welfare costs[9] Effective contraception is associated with significant cost savings from reduction in welfare payments (estimated to be >9 times than the healthcare saving costs). The number children born out of unintended pregnancies would significantly impact on future public expenditure in terms of social welfare, education, housing and other forms of public spending costs in addition to Medical costs. Recent study2 states this would account to 10% - 15% of the anticipated social welfare spending alone by 2020. Early testing / diagnosis of HIV reduce treatment costs - £12,600 per annum per patient compared to £23,442 with later diagnosis in addition to quality of life.
Based on the above evidence, if we know that our service works from the above mentioned indicators, we can quantity the savings from our sexual health spend. For every £1 effectively spend on contraception could have saved £11-£12.50 in NHS. We can multiply that figure by 9 to get an approximate reduction in welfare payments. For every HIV case diagnosed early, we could have £10,842 in health care cost in addition to social care / welfare cost on top of giving these patients improved quality of life years.
Sources [1] http://www.fpa.org.uk/news/unprotected-nation-cuts-sexual-health-services-cost-uk- %C2%A3136-billion [1] Kings Fund [1] McGuire A and Hughes D (1995) The economics of family planning services.
[7] http://www.fpa.org.uk/news/unprotected-nation-cuts-sexual-health-services-cost-uk-%C2%A3136-billion [8] Kings Fund [9] McGuire A and Hughes D (1995) The economics of family planning services.
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27.3 How do we know it is working? If this is working, we will be able to know from both the improvements in the quantitative indicators and qualitative feedback from clients / other stakeholders including providers.
Quantitative Indicators of progress
Reproductive Health: Continued year on year reduction in teenage pregnancy rates Reduction in repeat abortions compared to previous years particularly in older age groups Increase in the GP prescribed LARC uptake Percentage of those under 18 accessing abortion services better than the England average i.e. access to contraception and LARC good etc. Increase in the Community Pharmacy prescribed EHC – but not necessarily as declining trend may mean better access to contraceptive services? Increase in the number of condoms for safe sex practices linked with declining numbers of acute STI infections and reducing teenage conception rates?
Sexual Health Declining trends in all individual acute STIs e.g. Syphilis, Gonorrhoea, Genital Herpes, Genital Warts Declining trends in all combined new STI diagnoses (excluding Chlamydia aged <25) Significant increase in Chlamydia detection rate (15-24 year olds) i.e. 10% more than last year until we reach the expected national target. What about repeat infections?
HIV Increase trend in HIV testing uptake among MSM and Black Africans (%) Decreasing trend in % of late HIV diagnosis
Qualitative Indicator Decrease in the number of complaints received from clients using the sexual health services Increase in number of positive feedback from clients and other stakeholders User satisfaction surveys and action plans demonstrate progress year on year Positive reporting of young people friendly services No of health professional accessing the WISH training programme No of hits to the sexual health websites and other social media sites
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28 Appendix 11 - Public Health England MSM Action Plan 2015 This is a summary of the recent action plan published by Public Health England in 2015 on the health and wellbeing of gay, bisexual and other men who have sex with men. Summarised by Dr Ravi Balakrishnan MD FFPH, Consultant in Public Health Medicine, Buckinghamshire County Council. 28.1 Promoting the Health and Wellbeing of Gay, Bisexual and Other Men Who Have Sex with Men Public Health England launched an Action Plan in February 2015 to improve the health and wellbeing of gay, bisexual and other men who have sex with men (MSM). The document sets out plans to work with and support local and national government, the NHS and other relevant partners and third sector organisations and outlines specific objectives towards which progress will be tracked. PHE’s vision is to improve the health and wellbeing of MSM throughout the life course. Especially among MSM in those three areas of sexual health, mental health and substance use, as it relates to young MSM (starting well), MSM as they become adults (living well) and older MSM (ageing well). Evidence suggests that there are three interrelated areas in which the inequalities for MSM are most apparent: sexual health including HIV, mental health and wellbeing and the use of alcohol, drugs and tobacco. Statistics: Starting well (For info on living well and Ageing well please see full document)
Sexual Health & STI
85% of MSM report never having been taught about the biological or physical aspects of same- sex relationships MSM aged 16-24 years know consistently less about HIV than those aged 25-54 years. Same-sex relationships content missing from SRE, young MSM may be more likely to seek information from other sources. In the UK, younger MSM have higher rates of STIs; 1 in 4 of STI diagnoses among MSM are reported from men aged 16-24 years New HIV diagnoses among younger MSM increased by 30% from 340 in 2008 to 440 in 20128. 1/4 of MSM who were diagnosed <25 years, had acquired their infection in the previous 6 months; (ongoing HIV transmission)
Mental health and Well-Being Greater experience of discrimination including verbal, physical and sexual abuse in schools for MSM compared with heterosexuals Many young MSM not reporting incidents and little support offered. 99% had heard the term “gay” being used in a derogatory way or heard other homophobic language. 55% reported homophobic bullying, of those who had been bullied, 44% reported deliberately missing school as a consequence. Teachers report that boys who behave ‘like girls’, girls who behave ‘like boys’, young people with gay parents, friends or family members, and young people merely perceived to be gay can be all victims of homophobic bullying. LGBT adolescents are at greater risk for depressive symptoms and suicidal ideation compared with their heterosexual counterparts.
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Alcohol, drugs and tobacco LGB young people were almost twice as likely to use drugs and alcohol compared to heterosexual peers. They were also more likely to use harder drugs such as cocaine and to inject. Substance misuse was most strongly associated with homophobic and biphobic bullying. MSM aged 18-19 years were 2.4 times more likely to smoke and almost twice as likely to drink alcohol twice a week or more, compared to heterosexual men. 15 years olds who reported being bisexual were twice as likely to smoke regularly as their heterosexual and homosexual peers.
Public Health Interventions Sexual Health & STI MSM have a sexual health screen including an HIV test at least annually, and every three months if having sex without a condom with new or casual partners Mental health and wellbeing Range of interventions aimed at reducing victimisation of young LGBT people in schools e.g. Training for governors and leadership teams; learning resources for teachers, and classroom- based programmes focussing on bullying prevention and social emotional learning skills. Number of British generic and LGBT specific programmes that can help to support young MSM as they develop their sexual identity e.g. Rise Above programme aims to instil the skills and confidence in young people to develop resilience. Alcohol, drugs and tobacco Using MECC: brief interventions to assess and offer brief advice on alcohol, drug and tobacco use at each contact within the health service especially in sexual health care settings for Good treatment pathways and close liaison and partnership between alcohol and drug services and health settings most frequently used by MSM are important.
New Monitoring inequalities Indicators: Progress towards improving the health and wellbeing of MSM will be tracked against these specific objectives and we are working to develop indicators to track progress where there are current gaps: Reduction in the number of new HIV infections in MSM and improve the sexual health of MSM Reduction in the self-reported incidents of homophobic, biphobic and transphobic bullying in schools Close the gap in self-reported mental ill health between MSM and the general male population. Decrease the proportion of MSM reporting use of harmful illicit substances, including reduction in the proportion reporting ‘chemsex’ or steroid abuse. Reduce the proportion of MSM who are drinking above the lower risk levels. Close the gap in smoking prevalence amongst MSM and the general population of men in England.
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29 Appendix 12 - Buckinghamshire Sexual Health Website Buckinghamshire Sexual Health Website is an innovative and user-friendly website that provides detailed, up to date information on local sexual health services. It also provides information on sexually transmitted infections, pregnancy, contraception, safer sex and relationships. http://www.sexualhealthbucks.nhs.uk
Buckinghamshire Sexual Health Website has approximately 1000 hits per month so about 12,000 hits per year.
Other relevant links
[Facebook]
Buckinghamshire County Council, Sexual Health were also highly commended for the UK Brook Awards for our Young People's Sexual Health Programme http://www.brook.org.uk/uk-sexual- health-awards/2015-winners
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30 Appendix 13 - List of Wards in Buckinghamshire ID Ward Name District Name A01 Aston Clinton Aylesbury Vale District A02 Aylesbury Central Aylesbury Vale District A03 Bedgrove Aylesbury Vale District A04 Bierton Aylesbury Vale District A05 Brill Aylesbury Vale District A06 Buckingham North Aylesbury Vale District A07 Buckingham South Aylesbury Vale District A08 Cheddington Aylesbury Vale District A09 Coldharbour Aylesbury Vale District A10 Edlesborough Aylesbury Vale District A11 Elmhurst and Watermead Aylesbury Vale District A12 Gatehouse Aylesbury Vale District A13 Great Brickhill Aylesbury Vale District A14 Great Horwood Aylesbury Vale District A15 Grendon Underwood Aylesbury Vale District A16 Haddenham Aylesbury Vale District A17 Long Crendon Aylesbury Vale District A18 Luffield Abbey Aylesbury Vale District A19 Mandeville and Elm Farm Aylesbury Vale District A20 Marsh Gibbon Aylesbury Vale District A21 Newton Longville Aylesbury Vale District A22 Oakfield Aylesbury Vale District A23 Pitstone Aylesbury Vale District A24 Quainton Aylesbury Vale District A25 Quarrendon Aylesbury Vale District A26 Southcourt Aylesbury Vale District A27 Steeple Claydon Aylesbury Vale District A28 Stewkley Aylesbury Vale District A29 Tingewick Aylesbury Vale District A30 Waddesdon Aylesbury Vale District A31 Walton Court and Hawkslade Aylesbury Vale District A32 Weedon Aylesbury Vale District A33 Wendover Aylesbury Vale District A34 Wing Aylesbury Vale District A35 Wingrave Aylesbury Vale District A36 Winslow Aylesbury Vale District C01 Amersham Common Chiltern District C02 Amersham-on-the-Hill Chiltern District C03 Amersham Town Chiltern District C04 Asheridge Vale and Lowndes Chiltern District C05 Ashley Green, Latimer and Chenies Chiltern District C06 Austenwood Chiltern District C07 Ballinger, South Heath and Chartridge Chiltern District C08 Central Chiltern District C09 Chalfont Common Chiltern District C10 Chalfont St Giles Chiltern District
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C11 Chesham Bois and Weedon Hill Chiltern District C12 Cholesbury, The Lee and Bellingdon Chiltern District C13 Gold Hill Chiltern District C14 Great Missenden Chiltern District C15 Hilltop and Townsend Chiltern District C16 Holmer Green Chiltern District C17 Little Chalfont Chiltern District C18 Little Missenden Chiltern District C19 Newtown Chiltern District C20 Penn and Coleshill Chiltern District C21 Prestwood and Heath End Chiltern District C22 Ridgeway Chiltern District C23 St Mary's and Waterside Chiltern District C24 Seer Green Chiltern District C25 Vale Chiltern District S01 Beaconsfield North South Bucks District S02 Beaconsfield South South Bucks District S03 Beaconsfield West South Bucks District S04 Burnham Beeches South Bucks District S05 Burnham Church South Bucks District S06 Burnham Lent Rise South Bucks District S07 Denham North South Bucks District S08 Denham South South Bucks District S09 Dorney and Burnham South South Bucks District S10 Farnham Royal South Bucks District S11 Gerrards Cross East and Denham South West South Bucks District S12 Gerrards Cross North South Bucks District S13 Gerrards Cross South South Bucks District S14 Hedgerley and Fulmer South Bucks District S15 Iver Heath South Bucks District S16 Iver Village and Richings Park South Bucks District S17 Stoke Poges South Bucks District S18 Taplow South Bucks District S19 Wexham and Iver West South Bucks District W01 Abbey Wycombe District W02 Bledlow and Bradenham Wycombe District W03 Booker and Cressex Wycombe District W04 Bourne End-cum-Hedsor Wycombe District W05 Bowerdean Wycombe District W06 Chiltern Rise Wycombe District W07 Disraeli Wycombe District W08 Downley and Plomer Hill Wycombe District W09 Flackwell Heath and Little Marlow Wycombe District W10 Greater Hughenden Wycombe District W11 Greater Marlow Wycombe District W12 Hambleden Valley Wycombe District W13 Hazlemere North Wycombe District W14 Hazlemere South Wycombe District W15 Icknield Wycombe District
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W16 Lacey Green, Speen and the Hampdens Wycombe District W17 Marlow North and West Wycombe District W18 Marlow South East Wycombe District W19 Micklefield Wycombe District W20 Oakridge and Castlefield Wycombe District W21 Ryemead Wycombe District W22 Sands Wycombe District W23 Stokenchurch and Radnage Wycombe District W24 Terriers and Amersham Hill Wycombe District W25 Totteridge Wycombe District W26 The Risboroughs Wycombe District W27 The Wooburns Wycombe District
W28 Tylers Green and Loudwater Wycombe District
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31 Appendix 14 – Sexually Transmitted Infections 31.1 Introduction Sexually Transmissible Infections (STIs) are a high public health priority for UK as they are a significant source of morbidity that are directly amenable to control through prevention and population health interventions. STIs can result in acute symptoms, chronic infection, pain and longer term consequences including infertility, ectopic pregnancy, cervical or anal cancer and death. Some STIs can be transmitted by routes other than sexual contact, including blood-to-blood contact and from mother to child during pregnancy and childbirth. While some STIs, such as chlamydia, and gonorrhoea are curable, others such as Human Immunodeficiency Virus (HIV) and Herpes Simplex Virus (HSV) result in chronic lifelong infections. Since the emergence of HIV/AIDS an increasing level of attention has been given to groups at particular risk of contracting STIs to ensure that these priority populations have access to well- conceived high quality prevention, early intervention and treatment programs and services. The delivery of high quality population level data and both basic and clinical research has been crucial in the development of evidence to ensure the delivery of timely and appropriate responses to sexual health issues. Early detection of these infections and good clinical management and support are critical in reducing their negative impacts in terms of health status, personal and social well-being. Approaches to prevention focus on safe sex, vaccination programs (for hepatitis A and B, and HPV), needle and syringe programs (for hepatitis C and HIV) and a many other strategies derived from strong partnerships and co-operation with affected communities. There are over 30 different bacteria, viruses and parasites which are sexually transmissible listed below is a brief summary of the more common varieties.
31.2 Chlamydia Chlamydia is caused by the bacterium, Chlamydia trachomatis. The consequences of untreated chlamydia include ectopic pregnancy, pelvic inflammatory disease (PID) and epididymitis. Chlamydia is the most commonly notified disease in NSW, with young women aged 15-24 years being most frequently affected, and young heterosexual males also having high rates of infection. In males, symptomatic chlamydia manifests as urethritis, while in females the cervix is primarily affected resulting in abnormal vaginal discharge and abnormal vaginal bleeding. However, chlamydia is mostly asymptomatic and is often unknowingly transmitted through unprotected sexual encounters. Chlamydia can be treated with antibiotics.
31.3 Infectious Syphilis Syphilis is a systemic infection caused by a spirochete. Infectious (early) syphilis results in a primary lesion (chancre) and secondary eruption affecting skin and mucous membranes. In the cervix or rectum the painless chancre may often be unnoticed. If untreated, syphilis can result in chronic end organ complications. Syphilis can also enhance the transmission of HIV. Research has indicated that MSM are the predominant group affected by infectious syphilis, especially HIV positive MSM. Syphilis can be treated with antibiotics.
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31.4 Gonorrhoea Gonorrhoea is caused by the bacterium Neisseria gonorrhoea. Urethral infection in men mostly results in an acute urethral discharge. In women, genital infection is often asymptomatic but may result in mucopurulent cervicitis. Female genital infections can result in serious outcomes for the affected woman and neonates. Pharyngeal and anorectal infections may also occur. Gonorrhoea infection particularly affects MSM. Gonorrhoea can be treated with antibiotics. 31.5 HIV The Human Immunodeficiency Virus (HIV) is incorporated into the genetic material of CD4 white blood cells, leading to destruction of the CD4 cells and resultant damage to the immune system. HIV infection can initially be asymptomatic, although some people experience a sero-conversion illness, typically 2 weeks after acquisition of infection, with non-specific symptoms such as tiredness, fever, diarrhoea, rash, and other ‘flu-like symptoms. Indications of symptomatic HIV infection may include lack of energy, fevers and night sweats, persistent thrush in women and prolonged bouts of diarrhoea. During advanced stages of HIV infection, a person may develop any of a number of conditions including Kaposi’s sarcoma (KS), Pneumocystis, Pneumonia, Toxoplasmosis, Cytomegalovirus disease and Candidiasis (thrush) in the oral cavity, oesophagus or lungs. Drug treatment for HIV is combination antiretroviral therapy. These treatments are required for a person’s lifetime. As a result of these highly effective treatments, HIV is now considered to be a chronic disease, with those affected expected to live long lives. This re-definition has substantial implications for HIV diagnosis, management and care for both people living with HIV and their partners. There is strong evidence for higher rates of cardiovascular disease, cancers, cognitive and neurological disorders among people with HIV. A further issue for people with HIV is co-infection with other STIs. The rates of syphilis, for example, have been increasing at epidemic rates in HIV infected MSM. 31.6 Genital Warts Human papillomavirus (HPV) infection may cause benign anogenital Warts but infection with high- risk HPV types can cause anogenital and oropharyngeal cancers. Treatment of visible warts may be done in a variety of ways, including ablative treatments such as cryotherapy. However, these treatments often do not eradicate the wart virus. All girls aged 12 to 13 are offered HPV (human papilloma virus) vaccination as part of the NHS childhood vaccination programme. The vaccine protects against cervical cancer. It's usually given to girls in year eight at schools in England. 31.7 Hepatitis C (HCV) The hepatitis C virus is a ribonucleic acid (RNA) virus. The virus is transmitted by blood-to-blood contact. In Australia, most HCV is not sexually transmitted, but results from sharing of injecting paraphernalia among injecting drug users. In some overseas countries, HCV may be acquired via poorly sterilised equipment or inadequately screened blood being transfused. Although hepatitis C damages the liver, most people remain asymptomatic for decades. Some people experience ‘flu-like symptoms. Chronic hepatitis C may lead to cirrhosis of the liver, liver failure or liver cancer. There is no vaccine which prevents HCV. Treatments for people with hepatitis C are interferon and ribavirin, commonly termed ’combination therapy‘. 31.8 Hepatitis B (HBV) Hepatitis B is an infectious hepatitis caused by the hepatitis B virus (HBV). This infection has two possible phases; acute and chronic. Acute hepatitis B refers to newly acquired infections and, in most people with acute hepatitis, symptoms resolve over weeks to months and they are cured of the infection. However, a small number of people develop a very severe, life-threatening form of acute hepatitis called fulminant hepatitis. Chronic hepatitis B is an infection with HBV that lasts longer than 6 months.
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32 Appendix 15 - Sexual Health Glossary
AHPN African HIV Policy Network AIDS Acquired immune deficiency syndrome APMS Alternative Provider Medical Services BASHH British Association for Sexual Health and HIV BBVs Blood-borne viruses BHIVA British HIV Association BIS British Infection Society BME Black and minority ethnic CDSH Common Data Set for Sexual Health CHAPS Community HIV and AIDS Prevention Strategy CHINN Children’s HIV National Network CMO Chief Medical Officer DH Department of Health DMPA Depot medroxyprogesterone acetate EAGA Expert Advisory Group on AIDS EHC Emergency Hormonal Contraception EMA Early Medical abortion FE Further Education FRSH Faculty of Sexual & Reproductive Healthcare GMS General Medical Services GMSS Gay Men’s Sex Survey GP General Practitioner GUM Genitourinary Medicine GUMCAD Genitourinary Medicine Clinic Activity Dataset HAART Highly active antiretroviral therapy HIV Human immunodeficiency virus HPA Health Protection Agency HPV Human papillomavirus IDUs Injecting drug users IPV Interpersonal violence JSNA Joint Strategic Needs Assessment LA Local authority LAA Local area agreement LARC Long-acting reversible contraception LDP Local Delivery Plan LES Local enhanced service LINks Local Involvement Networks LSPs Local Strategic Partnerships MDT Multidisciplinary team MedFASH Medical Foundation for AIDS & Sexual Health MSM Men who have sex with men MRC Medical Research Council NAA Nucleic acid amplification NAATs Nucleic acid amplification technologies NAHIP National African HIV Prevention Programme NAM National AIDS Manual NAT National AIDS Trust
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NCB National Children’s Bureau NCSP National Chlamydia Screening Programme NHIVNA National HIV Nurses Association NHS National Health Service NICE National Institute for Health and Clinical Excellence NIHR National Institute for Health Research NIS National Indicator Set NST National Support Team OSS One Stop Shop QOF Quality and Outcomes Framework PBC Practice based commissioning PbR Payment by Results PCT Primary Care Trust PCTMS PCT Medical Services PEP Post-exposure prophylaxis PGDs Patient group directions PHSE Personal, social, health and economic PMS Personal Medical Services POCTs Point of care tests PSA Public Service Agreement RCGP Royal College of General Practitioners RCOG Royal College of Obstetricians and Gynaecologists RCN Royal College of Nursing RCP Royal College of Physicians RPHG Regional Public Health Group SARC Sexual Assault Referral Centre SCG Specialised Commissioning Group SHA Strategic Health Authority SHHRSC Sexual Health and HIV Research Strategy Committee SHIAG Independent Advisory Group on Sexual Health and HIV SLA Service level agreement SRE Sex and relationships education SSHA Society of Sexual Health Advisers STARHS Serological Testing Algorithm for Recent HIV Seroconversion STI Sexually transmitted infection STIF Sexually Transmitted Infections Foundation THT Terrence Higgins Trust TPIAG Teenage Pregnancy Independent Advisory Group YOI Young Offender
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33 Appendix 16 - References
1 Buckinghamshire County Council Director of Public Health’s Annual Report 2012-2013 http://www.buckscc.gov.uk/healthy-living/buckinghamshire-health-and-wellbeing-board/director- of-public-health-annual-report-2012-2013/ 2 Buckinghamshire County Council Joint Strategic Needs Assessment (JSNA) 2013 http://www.buckscc.gov.uk/community/knowing-bucks/joint-strategic-needs-assessment/ 3 Buckinghamshire County Council Sexual Health Profile 2013 http://www.buckscc.gov.uk/media/1037506/Sexual-health.pdf 4 Hind J. Commissioning Sexual Health services and interventions: Best practice guidance for local authorities. Sexual Health Policy Team, Department of Health March 2013 5 Sexual Health Commissioning- Frequently Asked Questions Local Government Association & Public Health England. Feb 2013 6 Public Health Outcomes Framework 2013-2016. Department of Health Nov 2013 7 A Framework for Sexual Health Improvement in England Department of Health March 2013 8 Quality criteria for young people friendly health services Department of Health. April 2011 9 PH51: Contraceptive services with a focus on young people up to the age of 25. NICE. March 2014 10 LGB21: NICE advice on HIV Testing. NICE. June 2014 11 PH34: Increasing the uptake of HIV testing among men who have sex with men. NICE. March 2011 12 PH33: Increasing the uptake of HIV testing among black Africans in England. NICE. March 2011 13 PH3: Prevention of sexually transmitted infections and under 18 conceptions. NICE. Feb 2007 14 CG30: NICE guidance on long acting reversible contraception (2005) 15 H McClean, K Radcliffe, A Sullivan, I Ahmed-Jushuf. 2012 BASHH statement on partner notification for sexually transmissible infections. BASHH. June 2013 16 Clutterbuck D et al. UK National Guidelines on safer sex advice The Clinical Effectiveness Group of the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) July 2012 17 British Association of Sexual Health and HIV : Standards for the Management of Sexually Transmitted Infections (2010 18 British Association of Sexual Health and HIV: Recommendations for Core Service Provision in Genitourinary Medicine. BASHH. 2005 19 A Quality Standard for Contraceptive Services Faculty of Sexual & Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists April 2014 20 Service Standards for Sexual & Reproductive Health Care. Faculty of Sexual & Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists. Jan 2013 21 Standards for the management of sexually transmitted infections (STIs). Medical Foundation for AIDS & Sexual Health (MEDFASH). Jan 2014 22 Recommended standards for sexual health services. Medical Foundation for AIDS & Sexual Health (MEDFASH). March 2005 23 Society of Sexual Health Advisers Manual. Society of Sexual Health Advisors (SSHA). 24 Making it work: a guide to whole system commissioning for sexual and reproductive health and HIV. Public Health England. 2014 DRAFT
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25 Time to test for HIV: Expanded healthcare and community HIV testing in England. Health Protection Agency. September 2011 26 Leaders’ Briefing: Addressing late HIV diagnosis through screening and testing. Public Health England. 2014 27 Addressing Late HIV Diagnosis through Screening and Testing: An Evidence Summary. Public Health England. April 2014 28 Aghaizu et al. HIV in the United Kingdom: 2013 Report. Public Health England. Nov 2013 29 Commissioning HIV Testing Services in England. NAT. Nov 2013 30 Owen J, Carroll C, Cooke J, Formby E, Hayteri M, Hirst J, Lloyd Jones M, Stapleton H, Stevenson M, Sutton A. School-linked sexual health services for young people (SSHYP): a survey and systematic review concerning current models, effectiveness, cost-effectiveness and research opportunities. Health Technol Assess. 2010 Jun. 31 Frankis JS1, Flowers P. The role of contact efficacy in evaluating sexual health promotion-- evidence-based outreach work within a public sex environment. Sex Health. 2006 May;3(2):79-85. 32 Theunissen KA, Hoebe CJ, Crutzen R, Kara-Zaïtri C, de Vries NK, van Bergen JE, van der Sande MA, Dukers-Muijrers NH1. Using intervention mapping for the development of a targeted secure web- based outreach strategy named SafeFriend, for Chlamydia trachomatis testing in young people at risk. BMC Public Health. 2013 Oct 22;13:996. doi: 10.1186/1471-2458-13-996. 33 Bell G and Potterat J. ‘Partner notification for sexually transmitted infections in the modern world: a practitioner perspective on challenges and opportunities’. Sexually Transmitted Infections 2011; 87: ii34–ii36 34 Nicholson C1, Jackson C, Marley J. A governance model for integrated primary/secondary care for the health-reforming first world - results of a systematic review. BMC Health Serv Res. 2013 Dec. 35 A review of the opportunities and restrictions of using digital solutions to support better self- testing for Sexually Transmitted Infections (STIs) 36 Minichiello V , Rahman S, Dune T, Scott J, Dowsett G. E-health: potential benefits and challenges in providing and accessing sexual health services. 2013 37 Innovations in sexual health provision: technology’s role in tackling inefficiency and supporting service development 38 Innovations in sexual health provision: technology’s role in tackling inefficiency and supporting service development 39 Making it work: a guide to whole system commissioning for sexual and reproductive health and HIV. Public Health England. 2014 DRAFT 40 Guse K1, Levine D, Martins S, Lira A, Gaarde J, Westmorland W, Gilliam M. Interventions using new digital media to improve adolescent sexual health: a systematic review. J Adolesc Health. 2012 Dec;51(6):535-43. doi: 10.1016/j.jadohealth.2012.03.014. Epub 2012 May 5. 41 Pellowski JA1, Kalichman SC. Recent advances (2011-2012) in technology-delivered interventions for people living with HIV. Curr HIV/AIDS Rep. 2012 Dec;9(4):326-34. doi: 10.1007/s11904-012- 0133-9. 42 Bailey JV1, Murray E, Rait G, Mercer CH, Morris RW, Peacock R, Cassell J, Nazareth I.Computer- based interventions for sexual health promotion: systematic review and meta-analyses. Int J STD AIDS. 2012 Jun 43 Bailey JV, Murray E, Rait G, Mercer CH, Morris RW, Peacock R, Cassell J, Nazareth I. Interactive computer-based interventions for sexual health promotion. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD006483. doi: 10.1002/14651858.CD006483.pub2.
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44 Schwarz EB1, Gerbert B, Gonzales R. Computer-assisted provision of emergency contraception a randomized controlled trial. J Gen Intern Med. 2008 Jun;23(6):794-9. doi: 10.1007/s11606-008- 0609-x. Epub 2008 Apr 9. 45 Richens J1, Copas A, Sadiq ST, Kingori P, McCarthy O, Jones V, Hay P, Miles K, Gilson R, Imrie J, Pakianathan M. A randomised controlled trial of computer-assisted interviewing in sexual health clinics. Sex Transm Infect. 2010 Aug;86(4):310-4. doi: 10.1136/sti.2010.043422. Epub 2010 Jun 15. 46 Roberto AJ1, Zimmerman RS, Carlyle KE, Abner EL. A computer-based approach to preventing pregnancy, STD, and HIV in rural adolescents. J Health Commun. 2007 Jan-Feb;12(1):53-76. 47 Marsch LA1, Grabinski MJ, Bickel WK, Desrosiers A, Guarino H, Muehlbach B, Solhkhah R, Taufique S, Acosta M. Computer-assisted HIV prevention for youth with substance use disorders. Subst Use Misuse. 2011;46(1):46-56. doi: 10.3109/10826084.2011. 521088. 48 Mevissen FE1, Ruiter RA, Meertens RM, Zimbile F, Schaalma HP Justify your love: testing an online STI-risk communication intervention designed to promote condom use and STI-testing. Psychol Health. 2011 Feb;26(2):205-21. doi: 10.1080/08870446.2011.531575. 49 Hersch RK1, Cook RF, Billings DW, Kaplan S, Murray D, Safren S, Goforth J, Spencer J. Test of a web- based program to improve adherence to HIV medications. AIDS Behav. 2013 Nov;17(9):2963-76. doi: 10.1007/s10461-013-0535-8. 50 A Framework for Sexual Health Improvement in England. Department of Health. March 2013 51 Noar SM1, Black HG, Pierce LB. Efficacy of computer technology-based HIV prevention interventions: a meta-analysis. AIDS. 2009 Jan 2;23(1):107-15. doi: 10.1097/QAD.0b013e32831c5500. 52 Fisher JD1, Amico KR, Fisher WA, Cornman DH, Shuper PA, Trayling C, Redding C, Barta W, Lemieux AF, Altice FL, Dieckhaus K, Friedland G; LifeWindows Team. Computer-based intervention in HIV clinical care setting improves antiretroviral adherence: the LifeWindows Project. AIDS Behav. 2011 Nov;15(8):1635-46. doi: 10.1007/s10461-011-9926-x. 53 Carpenter KM1, Stoner SA, Mikko AN, Dhanak LP, Parsons JT. Efficacy of a web-based intervention to reduce sexual risk in men who have sex with men. AIDS Behav. 2010 Jun;14(3):549-57. doi: 10.1007/s10461-009-9578-2. Epub 2009 Jun 5. 54 Reynolds NR1, Testa MA, Su M, Chesney MA, Neidig JL, Frank I, Smith S, Ickovics J, Robbins GK; AIDS Clinical Trials Group 731 and 384 Teams. Telephone support to improve antiretroviral medication adherence: a multisite, randomized controlled trial. J Acquir Immune Defic Syndr. 2008 Jan 1;47(1):62-8. 55 A Framework for Sexual Health Improvement in England. Department of Health. March 2013 56 Young SD, Cumberland WG, Lee SJ, Jaganath D, Szekeres G, Coates T. Social networking technologies as an emerging tool for HIV prevention: a cluster randomized trial. Ann Intern Med. 2013 Sep 3;159(5):318-24. doi: 10.7326/0003-4819-159-5-201309030-00005. 57 Jones K1, Baldwin KA, Lewis PR. The potential influence of a social media intervention on risky sexual behavior and Chlamydia incidence. J Community Health Nurs. 2012;29(2):106-20. doi: 10.1080/07370016.2012.670579. 58 Young SD. Analysis of online social networking peer health educators. Stud Health Technol Inform. 2012;181:253-9. 59 Sznitman S1, Vanable PA, Carey MP, Hennessy M, Brown LK, Valois RF, Stanton BF, Salazar LF, Diclemente R, Farber N, Romer D. Using culturally sensitive media messages to reduce HIV- associated sexual behavior in high-risk African American adolescents: results from a randomized trial. J Adolesc Health. 2011 Sep;49(3):244-51. doi: 10.1016/j.jadohealth.2010.12.007. Epub 2011 Apr 20.
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60 R W Peeling. Testing for sexually transmitted infections: a brave new world? Sex Transm Infect. Dec 2006 61 Suffoletto B1, Akers A, McGinnis KA, Calabria J, Wiesenfeld HC, Clark DB. A sex risk reduction text- message program for young adult females discharged from the emergency department. J Adolesc Health. 2013 Sep;53(3):387-93. doi: 10.1016/j.jadohealth.2013.04.006. Epub 2013 May 23. 62 Lewis MA1, Uhrig JD, Bann CM, Harris JL, Furberg RD, Coomes C, Kuhns LM. Tailored text messaging intervention for HIV adherence: a proof-of-concept study Health Psychol. 2013 Mar;32(3):248-53. doi: 10.1037/a0028109. Epub 2012 Apr 30. 63 Pellowski JA1, Kalichman SC. Recent advances (2011-2012) in technology-delivered interventions for people living with HIV. Curr HIV/AIDS Rep. 2012 Dec;9(4):326-34. doi: 10.1007/s11904-012- 0133-9. 64 van Velthoven MH1, Brusamento S, Majeed A, Car J. Scope and effectiveness of mobile phone messaging for HIV/AIDS care: a systematic review. Psychol Health Med. 2013;18(2):182-202. doi: 10.1080/13548506.2012.701310. Epub 2012 Jul 12. 65 Horvath T1, Azman H, Kennedy GE, Rutherford GW. Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection. Cochrane Database Syst Rev. 2012 Mar 14;3:CD009756. doi: 10.1002/14651858.CD009756. 66 Velasquez MM1, von Sternberg K, Johnson DH, Green C, Carbonari JP, Parsons JT. Reducing sexual risk behaviors and alcohol use among HIV-positive men who have sex with men: a randomized clinical trial. J Consult Clin Psychol. 2009 Aug;77(4):657-67. doi: 10.1037/a0015519. 67 Calderon Y1, Cowan E, Nickerson J, Mathew S, Fettig J, Rosenberg M, Brusalis C, Chou K, Leider J, Bauman L. Educational effectiveness of an HIV pretest video for adolescents: a randomized controlled trial. Pediatrics. 2011 May;127(5):911-6. doi: 10.1542/peds.2010-1443. Epub 2011 Apr 11. 68 Health Protection Agency (now Public Health England).Sexually transmitted infections in England, 2011. HealthProtection Report, 2012 69 Mercer C et al. ‘Building the bypass – implications of improved access to sexual healthcare’. Sexually Transmitted Infections 2012; 88: 9–15 70 Hughes G, Nichols T and Ison CA. Estimating the prevalenceof gonococcal resistance to antimicrobials inEngland and Wales. Sex Transm Infect 2011; 87: 526–531. 71 Hughes G, Nichols T and Ison CA. Estimating the prevalenceof gonococcal resistance to antimicrobials inEngland and Wales. Sex Transm Infect 2011; 87: 526–531. 72 British Association for Sexual Health and HIV, HealthProtection Agency. Guidance for gonorrhoea testing inEngland and Wales, 2010. 73 Kang M1, Skinner R, Usherwood T. Interventions for young people in Australia to reduce HIV and sexually transmissible infections: a systematic review. Sex Health. 2010 Jun;7(2):107-28. doi: 10.1071/SH09079. 74 National Institute for Health and Care Excellence. Contraceptive services with a focus on young people up to the age of 25. NICE public health guidance 51. 2014. 75 Hardee K, Gay J, Croce-Galis M, Afari-Dwamena NA. What HIV programs work for adolescent girls? J Acquir Immune Defic Syndr. 2014 Jul 1;66 Suppl 2:S176-85. 76 Larke N1, Cleophas-Mazige B, Plummer ML, Obasi AI, Rwakatare M, Todd J, Changalucha J, Weiss HA, Hayes RJ, Ross DA. Impact of the MEMA kwa Vijana adolescent sexual and reproductive health interventions on use of health services by young people in rural Mwanza, Tanzania: results of a cluster randomized trial. J Adolesc Health. 2010 Nov;47(5):512-22. doi: 10.1016/j.jadohealth.2010.03.020. Epub 2010 Jun 11.
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77 Burns FM1, Imrie JY, Nazroo J, Johnson AM, Fenton KA. Why the(y) wait? Key informant understandings of factors contributing to late presentation and poor utilization of HIV health and social care services by African migrants in Britain. AIDS Care. 2007 Jan 78 Gerressu M, Mercer CH, Cassell JA, et al. The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England. J Public Health (Oxf)2012; 34: 411–420 79 Braeken D, Rondinelli I. Sexual and reproductive health needs of young people: matching needs with systems. International Journal of Gynaecology &Obstetrics. 2012 80 Perry RC, Kayekjian KC,Braun RA, Cantu M,Sheoran B, Chung PJ. Adolescents' perspectives on the use of a text messaging service for preventive sexual health promotion. The Journal of Adolescent Health. 2012 81 Olsen JR, Cook PA, Forster S, et al. Accessibility of sexual health services in teenage sexual health service users: local area geospatial analysis. J Public Health (Oxf) 2012 82 Bender SS, Fulbright YK. Content analysis: A review of perceived barriers to sexual and reproductive health services by young people. European Journal of Contraception Reproductive HealthCare. 2013 83 Aston G and Bewley S. ‘Abortion and domestic violence’. The Obstetrician and Gynaecologist. 2009 84 Mittal M1, Senn TE, Carey MP. Mediators of the relation between partner violence and sexual risk behavior among women attending a sexually transmitted disease clinic. Sex Transm Dis. 2011 Jun;38(6):510-5. doi: 10.1097/OLQ.0b013e318207f59b. 85 MacMillan HL1, Wathen CN, Jamieson E, Boyle M, McNutt LA, Worster A, Lent B, Webb M; McMaster Violence Against Women Research Group. Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2006 Aug 86 Wyatt GE1, Longshore D, Chin D, Carmona JV, Loeb TB, Myers HF, Warda U, Liu H, Rivkin I. The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories. AIDS Behav. 2004 Dec
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