Providing seamless services for the sexual health needs of people living in Wales

1.National Care Pathways and Service Specification for allseamless sexual health services working together to improve patient care

2.Outcomes and indicators

July2011

Contents

Acknowledgements

  1. Introduction3
  2. Aims4
  3. Evidence base4
  4. Key policy drivers4
  5. General principles5
  6. Outcomes and indicators7
  7. Seamless sexual health services 14
  8. Primary care
  9. Community pharmacies 15
  10. General practice 17
  11. Integrated community and specialist sexual health services 21
  12. Termination of pregnancy 23
  13. Sterilisation services 26
  14. Psychosexual services 28
  15. Measuring compliance with service specification and impact on populations health 30

Appendix 1. Terms of reference and membership 31

Appendix 2. Trends in sexually transmitted infectionsin Wales 32

Appendix 3. Trends in legal abortions 34

Appendix 4. Trends in conceptions in Wales 35

Acknowledgements

Authorship: This action plan was written by Marion Lyons and Zoё Couzens with contributions from members of the Service Specification Task and Finish Group. It was edited and approved by the Service Specification Task and Finish Group. Terms of reference and membership Appendix 1

1.Introduction

The Welsh Government’s agenda in relation to sexual health is laid out in The Sexual Health and Wellbeing Action Plan for Wales 2010-2015 (WAG 2010). This supporting document describes the outcomes expected for the population’s sexual health through the delivery of quality seamless sexual health services in Wales and describes the care pathways underpinning them. This document deals with clinical care and does not describe the wider multiagency contribution to improving the nation’s sexual health.

In December 2004 the then Minister for Health and Social Care, Jane Hutt, as a result of a review into the state of HIV and sexual health services, decided to integrate the delivery of these services across Wales with clear standards for HIV and all sexual health services across Wales. The integration of contraceptive and genitourinary services was the focus of the Service Specification for Integrated Sexual Health Services – October 2005. The secondary care services have responded positively to this change in service delivery and secondary care services are now integrated/are integrating across Wales.

The restructuring of the NHS in 2008 provides a unique opportunity for Health Boards to address sexual health care provision across the whole health care sector.This service specification builds on what has already been achieved in secondary care and concentrates on the development of a seamless sexual health service through engagement with primary care including community pharmacies.

A national care pathway and service specification for HIV and AIDS was issued in July 2009 and will not be included in this document. (see

This service specification documents the recommended models of care patients can expect for the sexual health services – it includes the following:

  • Primary care and pharmacy provision
  • Integratedsexual health services – contraception and infection management
  • Termination of pregnancy (TOP) services
  • Sterilisation services
  • Psychosexual services

1.1 Aims

1.Ensure that effective treatments, interventions, support and services are provided to people when and where they need them.

2.Reduce health inequalities in relation to sexual health

3.Ensure that services provided are evidence based and appropriate, that unnecessary duplication is minimised and services provided are value for money

1.2 Evidence base

There has been a marked increase in sexually transmitted infections in Wales over the past decade. In 2008, the number of new Chlamydia infections diagnosed in Wales rose by 18% from the previous year and the rate has increased to 144 per 100,000. On the other hand, the downward trend for gonorrhoea continues with an 11% reduction in reported new cases in comparison to 2007. Rates of sexually transmitted infections are highest amongst those under 25 years.

Appendix 2: Trends in sexually transmitted infections in Wales reported by GUM

The latest conception figures for 2008 show teenage conception rates to be 13% lower than they were in 1999; recent progress has been slow; for under 18 conceptions the rate for 2008 was 42.2 per 1000 for women aged 15 – 17 compared to 44.9 in 2007. Regional differences in teenage conception rates persist: in 2008 (provisional figures) they vary from 27.1 to 73.5 per 1000 female residents aged 15-17 in Ceredigion and Merthyr Tydfil, respectively.

Appendix 34: Trends in terminations and conceptions in Wales

It is difficult to estimate the psychosexual needs of the population, it is generally accepted that current activity in psychosexual services is an underestimate.

1.3Key policy drivers are:

The Sexual Health and Wellbeing Action Plan for Wales2010-2015 (WAG 2010) emphasises the Welsh Government’s commitment to improving the sexual health of the population. The action plan’s objectives are to;

  • Increase sexual health and relationships literacy;
  • Improve access to good quality sexual health services;
  • Reduce the number of unintended pregnancies, particularly among teenage girls;
  • Reduce the rates of new Sexually Transmitted Infections (STI) and HIV;
  • Improve the health and social care for people living with HIV;
  • Reduce the number of new diagnoses of sexually transmitted Hepatitis B and the number of people at risk;
  • Strengthen the monitoring, surveillance and research of the population’s sexual health and well-being

Teenage conceptions are a target within the Welsh Assembly Government’s Strategy to Reduce Child Poverty (WAG 2010).The intended milestones in Wales for this indicator are; 2010 Milestone - that the rate of teenage conceptions under 16 years old for all local authority areas in Wales shall be no more than 13.4 per 1,000 girls aged 13-15 years, being one fifth of the target reduction. The ratio of teenage conceptions under 16 year olds for all local authority areas to the average for Wales will be no more than 1.49 (49%). 2020 Target - that the rate of teenage conceptions under 16 years old for all local authority areas in Wales shall be no more than 9.0 per 1,000 girls aged 13-15 years. The ratio of teenage conceptions under 16 years old for all local authority areas to the average for Wales shall be no more than 1.3 (30%).

1.4General principles

The following health care principles will apply to the provision of sexual health care:

  • provide services based on sound evidence wherever possible;
  • promote the independence, choice, dignity, privacy, respect, confidentiality and participation of service users;
  • acknowledge and respect a service user's gender, sexual orientation, age, physical or mental health ability, race, religion, culture, social background and lifestyle;
  • give service users maximum possible choice of service, appropriate to their needs and within the scope of the setting;
  • recognise the right of service users to have the optimum possible control over the service they receive and so gain the most benefit from it;
  • plan and provide the service in partnership with: service users; their family, friends or lay advocates (the "Relevant People"); support workers; and other independent and statutory agencies, to ensure that the service responds sensitively and flexibly to individual needs;
  • promote and advertise services and engage fully with the All Wales Sexual Health Network, each service having a designated individual who will be responsible for ensuring accurate information for the public on their service is available to the Network at all times
  • ensure that service users' views are taken into account in the running and development of the Service;
  • ensure that the service users' health is monitored and promoted;
  • workin a collaborative and co-ordinated way with other providers, both statutory and independent, to provide care to vulnerable groups.

2.Outcomes and indicators

Outcome 1. Fewer sexually transmitted infections and fewer unwanted pregnancies, less sexual ill health

OUTCOME 1 / ACTIVITY / SERVICE IMPROVEMENT MEASURE
High quality evidence based sexual health services using the latest technology to be the norm across Wales with 48 hour access available to all / Health Boards will ensure that services are designed and configured to ensure 48hour access to STI testing and treatment and to contraceptive services is achieved, if necessary by signposting. / Health Boards will provide Sexual Health Access data to Public Health Wales on a monthly basis
Sexual health care provision is configured to meet the needs of young people / The provision of easy access drop-in services that young people can, and are willing to, access and outreach services as appropriate, particularly in areas of greatest need, which as a minimum would provide sexual health advice, pregnancy testing and condoms, signposting and referral to other agencies. Clinical drop-in services for young people provided after school and out of hours / Health Boards will have evidence that they are working with local partners to improve access to services for young people
Services to engage with All Wales Sexual Health Network to ensure that all young people have ready access to accurate information on services available in their locality and to support referral pathways between service providers / The public and professionals to have accurate information on sexual health service provision to guide appropriate use of services and ensure timely access / Services will nominate an individual who will be responsible for ensuring that the Sexual Health Network has up to date information on local service provision
Unrestricted provision of all methods of LARCs available for all women within 6 weeks of request.
Use of LARCs to be actively promoted / Health Boards will show that LARCs are available within 6 weeks of request
Staff promote the use of LARCs, and provide contraception before discharge from early pregnancy units, postnatal care and termination of pregnancy service to more vulnerable women e.g. teenage mothers, women with substance misuse problems and sex workers
Robust and effective communication and liaison mechanisms are in place between sexual health service staff and maternity, termination of pregnancy / Maternity, Gynaecology and termination of pregnancy services will complete the All Wales Teenage Conception Audit form for all those under 19 years of age
Health Boards will have evidence that sexual health clinics have joint planning processes in place with maternity, gynaecology services, termination of pregnancy services
Availability of Specialist Psychosexual Counselling to meet the needs of the population
Equitable provision of medical treatment for sexual problems following appropriate assessment / All those in need are offered appropriate psychosexual support / Services can demonstrate that they have undertaken a robust local population needs assessment and have matched resources to need
Services will provide waiting time data to the Board annually
Clear links to be developed between sexual health and all vulnerable group services including advice on contraception for both men and women and where appropriate, support the provision of contraception, including LARCs in the substance misuse services / Robust and effective communication and liaison mechanisms are in place between sexual health service staff and staff in substance misuse services / Health Boards will have evidence that sexual health clinics have joint planning processes in place with substance misuse services and have documented pathways for service provision to clients of substance misuse services

1 Progestogen only injections, intrauterine devices or contraceptive implants

2 In the context of this service specification the key vulnerable groups are: teenagers, in particular looked after children and those at risk of sexual exploitation, those with substance misuse problems, homeless, asylum seekers, sex workers and those with learning difficulties/disabilities.

Outcome 2. A reduction in the health inequalities gap in sexual health

OUTCOME 1 / ACTIVITY / SERVICE IMPROVEMENT MEASURE
A reduction in health inequalities associated with teenage pregnancies / Teenagers most at risk will be supported in using LARCs through a number of local and national initiatives (reference teen preg doc) / Health Boards will demonstrate a reduction in teenage pregnancies and describe the multi agency partnership approach and initiatives that underpin it
A reduction in health inequalities associated with variable provision of contraceptive products / Women across Wales will have access to full range of contraceptives in line with the agreed all Wales therapeutic formulary for contraceptive provision. / Health Boards will demonstrate that contraceptive products are delivered in line with the agreed all Wales therapeutic formulary for contraceptive provision.
A reduction in health inequalities associated with the variable provision of termination of pregnancy services (access, timeliness and choice of method) / Termination of pregnancy services will be delivered according to the national care pathway / Health boards will demonstrate that by April 2013 the service needs (12+6, in line with RCOG guidelines) of the resident female population can be delivered locally
Health boards will demonstrate that by April 2012 local residents can self refer to termination of pregnancy services
A reduction in poorer sexual health outcomes in vulnerable groups / The sexual health needs of vulnerable groups will be met through the implementation of national guidelines and initiatives / Improvement in sexual health of vulnerable groups will be demonstrated by a reduction in unwanted pregnancies in these cohorts.
Improved access to services through the development and maintenance of a mobile phone application / All Wales Sexual Health Network supported by sexual health services will develop and maintain a sexual health mobile phone application / The public and professionals to have accurate information on sexual health service provision to guide appropriate use of services and timely access

Outcome 3. Efficient, value for money services

OUTCOME 1 / ACTIVITY / SERVICE IMPROVEMENT MEASURE
Quality IT systems that: supports joined up patient care; facilitates return of test results; improves efficiency of service; allows for clinical audit and supports data collection for quality indicators; improves patient experience (self triage, register for clinic appointment on line etc) and takes sexual health services to the 21st century by April 2013 / Health boards will work towards having robust integrated data collection mechanisms in place to provide statutory data and to ensure epidemiological and demographic data is used to plan services / Quality IT systems in place at all clinical sites by April 2013
Working together primary and secondary care will ensure that all services provided are value for money / Health Boards will plan services such that they are cost effective and efficient. This would include appropriate point of care testing (POCT) in outreach settings / Health Boards will provide costings annually for the provision of the following interventions by service provider:
LARCs
IUDs
Implanon
Vasectomy
and satisfy the Board that the service is value for money across all providers
An all Wales therapeutic formulary for contraceptive provision and management of sexually transmitted infections for first line treatment (excluding HIV care) / Provision of therapeutic products in delivery of sexual health will be guided by an all Wales therapeutic formulary / Public Health Wales will lead on the development,in collaboration with appropriate service representatives, of an an all Wales therapeutic formulary for contraceptive provision and management of sexually transmitted infections for first line treatment (excluding HIV care) To be in place by June 2012

1

Community pharmacy – essential services / Community pharmacy – National enhanced services3 / Core primary care services / Directed enhanced primary care service1 / Local enhanced primary care service2 / Integrated Community sexual health clinics / Integrated specialist sexual health services
Provision of sexual health promotion advice and signposting
Safeguarding and promoting welfare of vulnerable groups / Provision of sexual health promotion advice and signposting
Emergency contraceptive care#, signposting and onward referral
Safeguarding and promoting welfare of vulnerable groups / Provision of sexual health promotion advice and condoms
Emergency contraceptive care, signposting and onward referral
Sexual and contraceptive history taking
Free pregnancy testing
Contraceptive advice and access to all methods in Wales formulary and unrestricted access to all LARC methods (in house/by referral)
Information on all LARC methods
Initiation of bridging contraception
Cervical screening
Assessment and referral of men and women for STIs
Hepatitis B vaccination
Initial advice and referral for Termination of Pregnancy
Referral for male/female sterilisation
Referral pathways to psychosexual services including erectile dysfunction
Safeguarding and promoting welfare of vulnerable groups / Provision of sexual health promotion advice and condoms
Emergency contraceptive care
Sexual and contraceptive history taking
Free pregnancy testing
Contraceptive advice and access to all methods in Wales formulary and unrestricted access to all LARC methods (in house/by referral)
Information on all LARC methods
Initiation of bridging contraception
Cervical screening
Asymptomatic STI testing and appropriate BBV and syphilis testing
Result delivered to service user
Treatment for Chlamydia and genital warts
Facilitation of client based partner notification
Assessment and referral of symptomatic men and women for STIs
Hepatitis B vaccination
Initial advice and referral for
Termination of Pregnancy
Referral for male/female sterilisation
Referral pathways to psychosexual services including erectile dysfunction
Safeguarding and promoting welfare of vulnerable groups / Provision of sexual health promotion advice and condoms
Emergency contraceptive care all methods
Sexual and contraceptive history taking
Free pregnancy testing
Contraceptive advice and access to all methods in Wales formulary and unrestricted access to all LARC methods (in house/by referral)
Information on all LARC methods
Initiation of bridging contraception
Cervical screening
STI testing and treatment of asymptomatic and symptomatic men and women
Testing for BBV and syphilis
Result delivered to service user
Facilitation of client based partner notification
Hepatitis B vaccination
Initial advice and referral for
Termination of Pregnancy
Referral for male/female sterilisation
Referral pathways to psychosexual services including erectile dysfunction
Safeguarding and promoting welfare of vulnerable groups / Provision of sexual health promotion advice and condoms
Emergency contraceptive care
all methods
Sexual and contraceptive history taking
Free pregnancy testing
Contraceptive advice and access to all methods in Wales formulary and unrestricted access to all LARC methods (in house/by referral)
Information on all LARC methods
Initiation of bridging contraception
Cervical screening
Asymptomatic STI testing and appropriate BBV and syphilis testing
Result delivered to service user
Treatment for Chlamydia, genital warts and genital herpes
Facilitation of client based partner notification
Initial advice and referral for
Termination of Pregnancy
Referral for male/female sterilisation
Referral pathways to psychosexual services including erectile dysfunction
Safeguarding and promoting welfare of vulnerable groups / Provision of sexual health promotion advice and condoms
Emergency contraceptive care – all methods
Sexual and contraceptive history taking
Free pregnancy testing
Contraceptive advice and access to all methods in Wales formulary and unrestricted access to all LARC methods
complex contraception
Information on all LARC methods
Cervical screening
Asymptomatic STI testing
Complex STI management
and recurrent conditions
Testing for BBV and syphilis
Facilitation of client based partner notification and provider referral
Specialist health advice including one to one support and outreach where indicated
Referral pathways for specialist clinics: FGM, vulval clinics etc
Hepatitis B vaccination
Initial advice and referral for
Termination of Pregnancy
Referral for male/female sterilisation
Psychosexual/erectile dysfunction
Collaboration with SARC
Safeguarding and promoting welfare of vulnerable groups

Enhanced services are, in essence, elements of essential or additional services delivered to a higher specification, or medical services outside the normal scope of primary medical services, which are designed around the needs of the local population. Enhanced services are commissioned by Health Boards There are categories of enhanced services: