Sexual and Reproductive Health

Executive Summary

Having good sexual health is an important aspect of overall physical and emotional health and well-being. It is central to the development of some of the most important relationships in our lives. Any person who is sexually active could be negatively affected by their sexual health decisions and may need to take precautions or access sexual health services to maintain a positive and healthy sexual life.

In February 2016 Surrey County Council’s Public Health Team published a Sexual Health Needs Assessment for Surrey 2015 (SHNA) which looks in more depth at the areas discussed in this JSNA chapter. Additionally this chapter and the accompanying Tableau dashboard provides an update to the data in the published SHNA.
Who’s at risk and why?

Sexual ill-health can affect all parts of society and many different factors can influence relationships and safer sex, including:

  • personal attitudes and beliefs;
  • social norms;
  • peer pressure;
  • religious beliefs;
  • culture;
  • confidence and self-esteem;
  • misuse of drugs and alcohol; and
  • coercion and abuse.

The factors listed above are covered in more detail within the Sexual Health Needs Assessment, which looks at sexual health across the life course; under 16s; 16-24 year olds; Over 25 year olds and key population groups.

This JSNA chapter has particular focus on those most at risk within the Surrey population, namely;

Young people;

  • Men who have sex with men (MSM);
  • Black and Minority Ethnic (BAME);
  • Sex workers.

The level of need in the population

Sexually Transmitted Infections

  • Between 2009 and 2015 the largest increase in diagnosis for sexually transmitted infections (STIs) was for Syphilis, rising from 1.4 to 5 per 100,000 population and for Gonorrhoea rising from 14.7 to 37.5 per 100,000 population.
  • Chlamydia remains the most commonly diagnosed STI for young people aged 15-24 years old.

HIV testing and diagnosis

  • Whilst new diagnoses of HIV are significantly lower in Surrey (6.6 per 100,000) than the England average (12.1 per 100,000), 42.7% of diagnoses between 2013–2015 were late diagnosis of HIV.
  • In 2015 HIV testing coverage in Surrey for all persons was 75.7%, higher than the national average of 67.3%.
  • Uptake of testing was 84.6% for all persons and 94.7% in the men who have sex with men (MSM) population group.

Under 18 Conceptions

Average under 18 conception rates in Surrey have been falling consistently since 2011 to their lowest rate of 14.2 per 1,000 population (England average 22.8). Runnymede and Spelthorne continue to have the highest rates in Surrey at 19.7 and 20.3 per 1,000 population respectively.

Termination of Pregnancy

Surrey has higher than the national average rates of Termination of Pregnancy (ToP) in under 18s. This ranges from 48% in Runnymede to 80.6% in Reigate and Banstead. The England average is 51.1%. On average 38.1% of ToP in Surrey (all ages) were repeat ToP.
Services in relation to need

Sexual health services in Surrey are commissioned by a variety of partners including;

  • Surrey County Council
  • NHS England
  • Clinical Commissioning Groups
  • Surrey Police

Services include both clinical provision, and outreach based services which are often targeted towards population groups at particular risk of sexual ill health;

  • Genitourinary Medicine (GUM);
  • Contraceptive and sexual health services (CASH);
  • GP and Pharmacy;
  • Specialist services for young people;
  • Services for young parents;
  • Services for sex worker;
  • Services for gay men and men who have sex with men (MSM);
  • Sexual assault & sexual violence.

Unmet needs and service gaps

This JSNA chapter as in the SHNA recognises particular unmet need and service gaps in relation to;

  • Psychosexual Counselling
  • Menopause Services
  • Cervical Screening

What Works?

Following publication of the Public Health Outcomes Framework, the Department of Health published: A Framework for Sexual Health Improvement in England, which sets out 4 key objectives with associated ambitions.

Key objectives:

  • Improve the sexual health of the whole population;
  • Reduce inequalities and improve sexual health outcomes;
  • Build an open and honest culture where everyone is able to make informed and responsible choices about relationships and sex;
  • Recognise that sexual ill health can affect all parts of society, often when it is least expected.

In 2013, the Department of Health published a suggested service specification for integrated sexual health services. The proposed model aims to improve sexual health by providing easy access to services through open access ‘one stop shops’, where the majority of sexual health and contraceptive needs can be met at one site, usually by one health professional, in services with extended opening hours and in accessible locations.
Recommendations for Commissioning

The Surrey SHNA 2015 identified eight areas of recommendations for commissioning;

  • Schools and further education
  • Key population groups
  • Feedback from service users
  • Strengthening partnerships
  • Improving outcomes and choice
  • Using technology and online
  • Improving commissioning links
  • Unmet Need

These recommendations, the SHNA, national guidance on sexual health services and engagement with stakeholders have been used by the Public Health Team at Surrey County Council to develop the Surrey service specification. At the time of writing the new sexual health contract is in mobilisation and due to go live 1 April 2017.

Introduction

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“Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality… Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” (1)

Having good sexual health is an important aspect of overall physical and emotional health and well-being. It is central to the development of some of the most important relationships in our lives. Any person who is sexually active could be negatively affected by their sexual health decisions and may need to take precautions or access sexual health services to maintain a positive and healthy sexual life.

Sexual health services cover a range of topics;

  • Contraception
  • Sexually Transmitted Infections
  • Planning a pregnancy
  • Termination of pregnancy
  • Sexual problems
  • Sexual assault

Following publication of the Healthy Lives, Healthy People white paper (2) and changes introduced in the Health & Social Care Act 2012, (3) there were new arrangements for the commissioning of sexual health services from 1 April 2013, including a mandate for local authorities to ensure that comprehensive, open access, confidential sexual health services are available to all people who are present in their area (whether resident in that area or not). (4)

To accompany these changes the Department of Health published the Public Health Outcomes Framework which sets out desired outcomes for public health and how they will be achieved. (5) These outcomes focus on length and quality of life as well as reducing health inequalities. The importance of improving sexual health is acknowledged in the Public Health Outcomes Framework with the inclusion of three sexual health indicators:

  • under-18 conceptions;
  • Chlamydia diagnoses in 15–24-year-olds;
  • people presenting with HIV at a late stage of infection.

Public Health England’s Making it Work: A guide to whole system commissioning for

sexual health, reproductive health and HIV outlines the commissioning responsibilities for the three commissioning organisations; (6)

  • Local Authorities
  • Clinical Commissioning Groups
  • NHS England

In February 2016 Surrey County Council’s Public Health Team published a Sexual Health Needs Assessment (SHNA) for Surrey 2015 which looks in more depth at the areas discussed in this JSNA chapter. (7) Additionally this chapter provides an update to the data in the published SHNA and includes progress on the recommissioning of sexual health services in Surrey.

Who’s at risk and why?

Sexual ill-health can affect all parts of society and many different factors can influence relationships and safer sex, including:

  • personal attitudes and beliefs;
  • social norms;
  • peer pressure;
  • religious beliefs;
  • culture;
  • confidence and self-esteem;
  • misuse of drugs and alcohol; and
  • coercion and abuse. (8)

The factors listed above are covered in more detail within the Sexual Health Needs Assessment, which looks at sexual health across the life course; under 16s; 16-24 year olds; Over 25 year olds and key population groups. (7)

A Framework for Sexual Health Improvement also states “In order to improve sexual health outcomes, intervention programmes should be developed based on a robust evidence base and local needs. For example, the prevention of HIV and STIs should be targeted at those populations most at risk of infection; in England, this includes young people, gay and bisexual men and some black and ethnic minority groups.” (8) The particular risks of those identified above and additionally sex workers are outlined in this section.

Young People

Sexually Transmitted Infections

Young people 15-24years old continue to experience the highest rates of chlamydia, genital herpes and genital warts. In 2015 the most commonly diagnosed STI was chlamydia with 200,288 diagnoses, over 129,000 chlamydia diagnoses were made in England among young people aged 15 to 24 years (64%). (9)

In 2015, among heterosexuals diagnosed, 15 to 24-year-olds accounted for 62% of those with chlamydia, 52% with gonorrhoea, 51% with genital warts, and 41% with genital herpes. (9)

Under 18 conceptions

Office for National Statistics (2014) states that the under 18 conception rate for 2014 is the lowest since 1969 at 22.9 conceptions per thousand women aged 15 to 17 (10). The estimated number of conceptions to women aged under 18 fell to 22,653 in 2014, compared with 24,306 in 2013, a decrease of 6.8%.

It is widely understood that teenage pregnancy and early parenthood can be associated with poor educational achievement, poor physical and mental health, social isolation, poverty and related factors.

There is also a growing recognition that socio-economic disadvantage can be both a cause and a consequence of teenage motherhood. Teenage pregnancy rates are a well-established and evidence based indicator of deprivation and inequality with 50% of all teenage conceptions occurring in the top 20% most deprived wards in England. Poor self-esteem, lack of aspiration and alcohol misuse increase the likelihood of a teenage pregnancy.
Young Parents

Public Health England (2016) in their Framework for Young People (11) state “like all parents, teenage mothers and young fathers want to do the best for their children and some manage very well; but for many their health, education and economic outcomes remain disproportionately poor which affects the life chances for them and the next generation of children.”

The babies of young parents can face more health problems such as premature birth or low birth weight and higher rates of infant mortality. Teenage mothers themselves may also have experience health problems. For example, postnatal depression is three times more likely in teenage mothers; smoking in pregnancy is twice as common and teenage mothers are one third less likely to breast feed. 2 in 3 teenage mothers experience relationship breakdown in pregnancy or the 3 years after birth. There is little data on teenage fathers but health, economic and employment outcomes seem to be similar to those of young mothers; men who were young fathers are twice as likely to be unemployed at 30

Termination of Pregnancy

According to the Department of Health (2015) Abortion Statistics, England and Wales (12) the total number of terminations remains fairly constant at 185,824, 0.7% higher than in 2014 (184,571) and 0.3% less than in 2005 (186,416).

Around half of all under 18 conceptions in England lead to a termination. The rate for England and Wales equates to 9.9 per 1,000 women compared with 11.1 in 2014 and 17.8 in 2005. In young women under 16 the rate is 2.0 per 1,000. Currently the termination rate is highest in those aged 21 (at 28.7 per 1,000).

Repeat terminations

38% of terminations in 2015 were to women who had already had one or more terminations. This varies according to age group;

  • 46% of terminations to women aged 25 and over
  • 26% of terminations to women aged under 25
  • 10 % of terminations to women aged under 18

Safeguarding

Safeguarding is integral to sexual health services, staff are trained to recognise and respond appropriately to safeguarding issues across all ages including domestic violence, child sexual exploitation and female genital mutilation. Safeguarding is discussed in XX JSNA chapter.

Men who have sex with men

According to PHE’s Infection Report 2015 (13) large increases in STI diagnoses were seen in MSM, including a 21% increase in gonorrhoea (the most commonly diagnosed STI among MSM in 2015) and a 19% increase in syphilis. High levels of condomless sex thought to be accountable for most of this rise, however some of the increase in gonorrhoea and chlamydia diagnoses in MSM may be due to better detection.

While the vast majority do not have HIV, gay, bisexual men and other men who have sex with men (MSM) continue to be the group most affected by HIV infection. In 2013, 59 per 1,000 MSM aged 15-59 years, meaning an estimated 43, 500 (40,200-48,200) MSM were living with HIV in the UK. An estimated 7,200 (16%) MSM living with HIV were unaware of their infection. (13)

The number of MSM diagnosed with HIV infection remained high, with 3,250 men reported in 2013. This reflects both on-going high levels of HIV transmission and an increase in HIV testing. There was a decline in the proportion of men diagnosed late (from 43% in 2004 to 31% in 2013) however, the absolute number of men diagnosed late remained high and stable at around 1,000. (13)

Black and Minority Ethnic (BAME) Populations

The United Kingdom’s black and minority ethnic populations continue to be disproportionately affected by poor sexual health. The groups affected and their experiences of HIV and STIs vary greatly, reflecting the diversity present in the migratory patterns, socio-economic circumstances, and experiences of disadvantage and discrimination in these populations. Variation in the transmission of STIs amongst BAME groups is further influenced by a number of factors, including, diverse sexual attitudes and behaviours, patterns of sexual mixing, language barriers and access to sexual health services. For example, black-African people in the UK are particularly affected by HIV but, by comparison, black-Caribbean populations in the UK experience a higher incidence of acute bacterial STIs, such as gonorrhoea, chlamydia and syphilis and lower HIV rates.

The large majority of black-African people living in the UK do not have HIV. Nevertheless, in 2013, an estimated 38,700 black-Africans were HIV positive and this group constitutes two-thirds (65%, 38,700) of all heterosexual people living with HIV. The HIV prevalence rate among black-African heterosexuals is 56 per 1,000 population aged 15-59 years (41 per 1,000 men and 71 per 1,000 women). Almost two in five (38%) black-African men and one in three (31%) black-African women living with HIV remained unaware of their infection. (13)

HIV Late diagnosis

A late diagnosis is defined as having a CD4 count below 350 cells/mm³ within three months of diagnosis. Previously it meant having a CD4 count below 200 cells/mm³ within 91 days of diagnosis; this is now referred to as a very late HIV diagnosis.

Late diagnosis reduces health outcomes for people living with HIV, as well as increasing the likelihood of onward transmission of HIV. In addition to the negative effects of late HIV diagnosis on an individual’s and population’s health, costs of late diagnosis are substantial, to both the NHS and to local authorities. The lifetime treatment cost of living with HIV is estimated to be around £360,000. According to NICE (2014) (14) the cost of HIV care in the first year after diagnosis is twice as much if the person is diagnosed late because of the significant rates of morbidity linked to late diagnosis. The costs of HIV care remain 50% higher for each year after diagnosis if the diagnosis is late.

This group had a ten-fold increase in the risk of death within a year of diagnosis compared to those diagnosed with a CD4 count ˃350 cells/mm3 (25 vs. 2 per 1,000 population). (13)

Sex Workers

Sex work or prostitution carries a high risk of sexually transmitted infections for both the sex worker and their customers. The people involved in sex work often face challenges such as substance use, limited access to services, violence and exploitation. It is estimated that there are about 80,000 sex workers in the UK up to 20,000 of which could be migrants. (15) Street-based sex work accounts for about one third of this number with indoor activity such as brothels, escort work and ‘parlours’ accounting for the remainder.

There are thought to be over 120 men and women involved in sex work in Surrey. It is difficult to give an accurate figure for the number of sex workers due to the covert nature of sex work and its transient nature. In Surrey there is no street based sex work or ‘red light district’. Sex work in Surrey is indoor and takes place in brothels, through escort agencies, in sex workers’ homes, at lorry parks, or ad hoc in a variety of places such as pub toilets, cars and wooded areas. There tends to be clusters of sex work in areas close to Heathrow and Gatwick airports and the larger towns in Surrey. One to one contact with sex workers takes place in a variety of settings: working flats or brothels; cafes or other public places; in a worker’s car; escort agency base; clinic or other health service venue; sex worker’s own home; hotels; at social events; lorry parks/truck stops and ‘dogging’ sites. Engaging those involved in sex work with services is not easy due to the legal issues associated with prostitution and their fears around disclosure. This can lead to sex workers being marginalised, leaving them vulnerable to violence and isolation.

The level of need in the population

All data presented in this section is available on the Tableau dashboard for Sexual Health. The dashboard has interactive charts, graphs and maps for Surrey and its borough and districts.

Sexually Transmitted Infections

Diagnostic rates for Sexually Transmitted Infections in Surrey are generally lower than the regional and national averages. However the trends seen nationally for increases in Gonorrhoea and Syphilis diagnoses have been seen locally;

  • Between 2009 and 2015 the largest increase in diagnosis for STIs was for Syphilis, rising from 1.4 to 5 per 100,000 population and for Gonorrhoea rising from 14.7 to 37.5 per 100,000 population.
  • Chlamydia remains the most commonly diagnosed STI for young people aged 15-24 years old. The detection rate in Surrey is 1182.2 per 100,000 population.

Other STIs

  • Genital Herpes: 57.4 per 1,000 compared to South East 51 per 1,000, and England 57.6 per 1,000
  • Genital Warts: 106.9 per 1,000 compared to South East 108.1 per 1,000 and England 118.9 per 1,000

HIV

  • In 2015 HIV testing coverage in Surrey for all persons was 75.7%, higher than the national average of 67.3%.
  • Uptake of testing was 84.6% for all persons and 94.7% in the men who have sex with men (MSM) population group.
  • Prevalence of HIV ranges across Surrey from 1.1 per 1,000 population (Epsom and Ewell) to 1.9 per 1,000 (Woking). Prevalence for all Boroughs and Districts is lower than the England rate of 2.3 per 1,000.
  • Whilst new diagnoses of HIV are significantly lower in Surrey (6.6 per 100,000) than the England average (12.1 per 100,000), 42.7% of diagnoses between 2013–2015 were late diagnosis of HIV.

Under 18 conceptions

  • In line with national data trends that show a continuing decrease in the rates of conception in under 18 year olds, Surrey’s average has been falling consistently since 2011.
  • Rates are currently at their lowest of 14.2 per 1,000 population, compared to a South East region average of 18.8 and England average of 22.8 per 1,000.
  • Runnymede and Spelthorne continue to have the highest rates in Surrey at 19.7 and 20.3 per 1,000 population respectively.

Prescribed Long Acting Reversible Contraceptives (LARC)

In 2014, LARC contraceptive methods (excluding injection) were more commonly prescribed by GP than Sexual and Reproductive Health (SRH) Services.

  • GPs prescribed 38.8 per 1,000 population, which is higher than the England average 32.3 per 1,000.
  • SRH prescribed 13.4 per 1,000 population, which is lower than the England average 17.8 per 1,000.
  • Combined prescription figures show Surrey Heath prescribed the most at a rate of 73.4 per 1,000, Runnymede the lowest at 29.3 per 1,000.
  • 2014 data shows on average more over 25 year olds were choosing Long Acting Reversible Contraceptives (LARC) at Sexual and Reproductive Health services (SRH) than under 25 year olds, 36.4% compared to 16.2%.

Termination of pregnancy

  • Surrey has significantly higher than the national average rate of Termination of Pregnancy (ToP) in under 18s, 64.8%
  • Rates for under 18s ToP ranges greatly from 48% in Runnymede to 80.6% in Reigate and Banstead.
  • The South East region average is 53.2%, England average is 51.1%.

Repeat Terminations

Surrey has high rates of repeat terminations (woman has had one or more terminations). On average 38.1% of ToP in Surrey in 2015 (for all ages) were repeat ToP.

  • 27.9% of terminations to women aged under 25 were repeat ToP. The highest was 32.1% in Surrey Downs CCG
  • 44.9% of terminations to women aged 25 and over were repeat ToP. The highest was 51.1% in Surrey Heath CCG

Services in relation to need.

The following section outlines current sexual health services in Surrey. This includes both clinical and outreach based services commissioned by a variety of partners including;

  • Surrey County Council
  • NHS England
  • Clinical Commissioning Groups
  • Surrey Police

These services, including service aims, uptake and recent work is explained in further detail throughout the Sexual Health Needs Assessment. (7)

Figure 1 shows Public Health Commissioned Sexual Health Services in Surrey

Currently in Surrey there are three main Genitourinary Medicine (GUM) sexual health services providing first and follow up appointments. These are as follows;

  • Frimley Park Hospital.
  • Ashford and St Peter’s Hospital.
  • Virgin Care; Leatherhead Hospital, Buryfields (Guildford), Earnsdale (Redhill) and Woking Community Hospital.

Additionally Virgin Care provides contraceptive and sexual health services (CASH) with approximately 21,500 attendances per annum and sexual health improvement and promotion including outreach.

GPs provide the contraceptive implant and Intrauterine Contraceptive Device (coil), through Public Health Agreements (PHAs), totalling over 10,000 procedures per annum. Pharmacies provide emergency hormonal contraception (EHC), approximately 360 per annum, to under 25 year olds.

Sexual health services are open access. As such there are around 15,000 attendances by Surrey residents to out of area services. Around 50% of out of area attendances are made to bordering counties or London Boroughs.

Surrey County Council Services for Young People

Through the Community Youth Work Service, Surrey County Council Services for Young People provides planned and opportunistic input for young people on relationships, sexual health, access to condoms and support to access other services as appropriate. Surrey Services for Young People have recently updated their Relationships & Sex Education and Sexual Health Policy to support and guide this work.

Young Parent’s Groups

There are a number of Young Parent’s Groups operating in Surrey. Groups are run by either Services for Young People, health services (midwives or health visitors) or Children’s Centres. In some cases they are run in partnership. The groups provide support with a wide range of issues affecting young parents in an appropriate informal setting including advice on parenting, sexual health, contraception and services available locally. Additionally partners across Surrey County Council, maternity, Family Nurse Partnership and Parent Infant Mental Health services are working together to develop a framework to support young mothers and fathers. The framework will include care pathways and links to available support. The Young Parents’ Framework will form part of a Surrey-wide Parenting Strategy.

Sexual Health Outreach Workers

Two part-time nurses working in Spelthorne and in Elmbridge and Mole Valley are commissioned by Surrey County Council Public Health and provided by Virgin Care. The aim of these roles is to provide a flexible service for young people in a variety of settings.

The Family Nurse Partnership

The Family Nurse Partnership (FNP) is an evidence-based, preventive programme offered to young mothers having their first baby. Support begins in early pregnancy and its focus is the future health and well-being of the child, as well as the future social benefits and economic self-sufficiency of the parents. The FNP supports young mothers to develop decision making skills and access services including contraception and STI testing.

Parent and Infant Mental Health Service (PIMHS)

The Parent Infant Mental Health Service (PIMHS), works with parents expecting a baby and with babies up to the age of one year. PIMHS is a small team of specialist health visitors, child psychotherapists and perinatal therapists. PIMHS build on the strengths of parents while recognising the challenges they face in developing a positive relationship with their infant. Supporting parents when they struggle to relate to or have any positive feelings about their babies.

Specialist Services for Young People

Surrey has a number of free to user services that are commissioned specifically for young people under 25 years old.

  • Chlamydia and Gonorrhoea testing
  • Condom distribution scheme
  • Emergency contraception

These are delivered in a variety of settings from schools and colleges, outreach and youth centres, clinic and in pharmacies under Public Health Agreements.

Sex Worker Services

The following services are available for sex workers living and/or working in Surrey:

  • Harm Reduction Development Worker for sex workers. This post has a key role in liaising with other key services in and Surrey and the south east region to ensure access to appropriate services to promote the sexual health and physical & emotional safety of sex workers living and/or working in Surrey.
  • ‘Delta’ fast-track access to GUM clinics
  • Surrey Police single point of contact for sex workers
  • Ugly Mugs Scheme

Services for Gay Men and Men who have Sex with Men (MSM)

The following services for gay men & MSM are currently available in Surrey:

  • Harm Reduction Development Worker for Gay Men & MSM. This post has a key role in raising awareness of discrimination towards gay men & MSM and promoting and developing anti-discriminatory practise in order to address health inequalities experienced by gay men & MSM.
  • Surrey Police Lesbian and Gay Liaison Officers (LAGLO)
  • Married Men’s Groups
  • Terrence Higgins Trust Surrey
  • Specialist Clinics for Gay Men
  • Outline Surrey
  • Twister: provision for LGBT+ young people aged 13-19 (25 for those with Special Educational Needs and/ or Disabilities)

Currently there are no sexual health services or clinic sessions specifically for gay men or MSM operating in Surrey.

Sexual Assault & Sexual Violence

Sexual Assault and Referral Centres (SARCs) aim to promote recovery and health following a rape or sexual assault, whether or not the victim wishes to report it to the police. A SARC typically provides specialist clinical care and follow-up to victims of acute sexual violence, including sexual health screening and emergency contraception, usually in one place, regardless of gender, age, ethnicity or disability. In addition, victims can choose to undergo a forensic medical examination if they wish. Surrey SARC is provided by Solace and located at Cobham Community Hospital.

The Sexual Trauma and Recovery Support Service (STARS) is provided by Surrey and Boarders Partnership (SABP) as part of their child and adolescent mental health services (CAMHS) work. It seeks to provide, and to support others providing, therapeutic intervention to children, young people and parents/carers have been affected by sexual abuse to promote and improve their emotional well-being and positively influence mental health and educational outcomes.

Unmet needs and service gaps

Psychosexual Counselling

Sexual health services in Surrey report a lack of provision for psychosexual counselling leading to reluctance on the part of sexual health professionals to refer on for psychosexual counselling as they are concerned about long waiting times at the few services that are available.

Menopause Services

Sexual health services in Surrey report that they frequently identify a need for specialist menopause services among women. These services can include Long Acting Reversible Contraceptives (LARC) for non-contraceptive purposes.

Cervical Screening

Sexual health services report that a number of women are being referred to them for smear tests when the GP practice does not offer this service or does not have suitably trained female staff.

What works

Following publication of the Public Health Outcomes Framework, (5) the Department of Health published: A Framework for Sexual Health Improvement in England, which sets out 4 key objectives with associated ambitions. (8)
Key objectives:

  • Improve the sexual health of the whole population;
  • Reduce inequalities and improve sexual health outcomes;
  • Build an open and honest culture where everyone is able to make informed and responsible choices about relationships and sex;
  • Recognise that sexual ill health can affect all parts of society, often when it is least expected.

In 2013, the Department of Health published a suggested service specification for integrated sexual health services. (16) The proposed model aims to improve sexual health by providing easy access to services through open access ‘one stop shops’, where the majority of sexual health and contraceptive needs can be met at one site, usually by one health professional, in services with extended opening hours and in accessible locations.

Services support delivery against the three main sexual health Public Health Outcome Framework (PHOF) measures and provide open access, cost-effective, high quality provision for contraception, and the prevention, diagnosis and management of sexually transmitted infections. (5) These are according to evidence-based protocols and adapted to the needs of local populations.

The proposed integrated service model is characterised by:

  • being provided on an open access basis and available to anyone requiring care, irrespective of their age, place of residence or GP registration, without referral;
  • having walk-in and appointment clinics, including evenings and Saturdays;
  • using a hub and spoke model of care (working with local general practices and linking into local outreach work);
  • multidisciplinary working;
  • providing a full range of sexual health services;
  • providing interpretation services for clients whose first language is not English and who require interpretation;
  • providing services to women and men of any age;
  • proving evidence based care centred on recognised national best practice guidance where this exists;
  • delivery in broad accordance with the Level 1, 2 and 3 service model which is well established for sexual health service provision including the following elements: self-managed care; basic and intermediate care; complex service provision. (8)

Recommendations for Commissioning

Based on the Integrated Sexual Health Services: National Service Specification (16) the Public Health Team at Surrey County Council are in the process of recommissioning a new Integrated Sexual Health service.

The Surrey service specification was developed using the findings, recommendations and key messages from the Sexual Health Needs Assessment (2015) and with key partners who attended a Concept Day in December 2015. At the Concept Day, Public Health aimed to engage with

the;

  • local community, service users, carers and their representatives;
  • the provider market;
  • Surrey County Council and other relevant public sector partners including CCGs, Districts & Borough Council’s, NHS England and Public Health England.

Figure 2 shows the Integrated Delivery (complete pathway)

The Integrated Delivery (complete pathway) shows individual contracts for Primary Care. Integrated delivery by 1 lead provider (with or without sub-contracts) on a countywide basis with underpinning Memorandum of Understanding.

The new contract, which will include a Memorandum of Understanding with NHS England for HIV treatment and care, will begin 1 April 2017.

Recommendations from the SHNA (7)

Schools and further education

  • Ensure schools have access to appropriate resources for PSHE and RSE.
  • Encourage schools to include work on homophobic bullying and positive relationships within their PSHE work.
  • Ensure sexual health is included in school nurse remit in the recommission of community services.
  • Provide Surrey Universities with links to accurate and current sexual health information and services via the Healthy Surrey website.
  • Look at the opportunities for University-based, dedicated sexual health services as part of future service commissioning.

Key population groups

  • Link with professionals who work with children and young people who may miss out on education, to ensure their needs are met.
  • Link with professionals who work with looked after children and young people to ensure their needs are met.
  • Ensure suitable pathway in place for young parents with engagement from relevant stakeholders.
  • Continue to engage with at-risk groups such as MSM, Sex Workers and the Black African population.
  • Increase access to STI testing and treatment for at-risk groups
  • Increase early diagnosis of HIV for at-risk groups

Feedback from service users

  • Ensure young people’s views are sought in service design and that responses are considered in new service design.
  • Work with Services for Young People to gain detailed feedback from young people and service users to identify what type of services they would like and how and where they would like them to be available.
  • Work with all sexual health service providers to collect feedback on service and experience from service users.

Strengthening partnerships

  • Extend the role of the existing Sexual Health Operational Group to provide a forum for professionals working in sexual health or related services.
  • Establish an annual network meeting for representatives of organisations working in sexual health or related services e.g. substance misuse, colleagues in Borough and District Councils.
  • Continue to link with Surrey Health Protection Forum to increase awareness and uptake of HPV vaccination.
  • Contribute to and implement recommendations made by, related task groups such as FGM, CSE and the Young Parents’ Pathway.

Improving outcomes and choice

  • Ensure sexual health services have been Equality Impact Assessed and appropriately meet the needs of people with protected characteristics.
  • Increase awareness of sexually transmitted infection testing with young people.
  • Increase number of young people screened and treated (for Chlamydia and Gonorrhoea) where necessary.
  • Review the evidence on contraceptive choices in maternity services post-birth and implement accordingly.
  • Improve the offer to young people from pharmacy, through the provision of a suite of services including EHC, condom distribution scheme and Chlamydia/ Gonorrhoea testing.
  • Move towards an integrated GUM and CASH service, where clinicians are dual trained.
  • Review available training and ensure that everyone who delivers sexual health services or sexual health promotion has access to appropriate training.
  • Work with sexual health services to better understand and address the increase in ChemSex related attendances at GUM services

Using technology and online

  • Map location of EHC providers and identify any gaps.
  • Promote young people’s services including free EHC and availability through the Health Surrey website.
  • Use Pharmoutcomes system to better understand uptake of EHC in pharmacy settings and inform future work on EHC.
  • Look at opportunities to provide an online datasystem to support the condom distribution scheme, improving access for young people and reducing impact on staff.

Improving commissioning links

  • Work with CCGs to ensure termination providers in Surrey provide consistent contraception information to reduce young women having repeat terminations.
  • Work with colleagues in NHS England to join the HIV pathway for initial testing and treatment and care

Unmet Need

  • Ensure consistent provision of contraception provided for non-contraceptive purposes across Surrey.
  • Ensure psychosexual counselling relative to local need is included within the future of Public Health commissioning of sexual health services.
  • Work with Surrey Health Protection Forum to maximise opportunistic cervical screening within sexual health services.

Key contacts

Lisa Andrews Senior Public Health Lead SCC; lisa.Andrews@surreycc.gov.uk
Hannah Bishop Public Health Lead SCC; hannah.bishop@surreycc.gov.uk
Alessandra Denotti Public Health analyst SCC; alessandra.denotti@surreycc.gov.uk
JSNA Coordinator: Jon Walker Advanced Public Health Information analyst SCC; jon.walker@surreycc.gov.uk

Chapter References

  1. World Health Organisation. Sexual and reproductive health: Defining sexual health. Geneva: World Health Organization; 2002 [accessed 7 November 2016]. Available from: http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/
  2. Department of Health (2010). Healthy Lives, Healthy People: our strategy for public health in England [accessed 7 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216096/dh_127424.pdf.
  3. HM Government (2012). Health & Social Care Act, 2012 [accessed 7 November 2016]. Available from: http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted , accessed 7 November 2016)
  4. Department of Health (2013). Sexual Health Services: Key Principles for Cross Charging [accessed 7 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226325/Sexual_Health_Key_Principles_for_cross_charging.pdf.
  5. Department of Health (2012). Public Health Outcomes Framework 2013-2016 [accessed 7 November 2016]. Available from: https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency.
  6. Public Health England (2014 revised 2015). Making it work: A guide to whole system commissioning for sexual health, reproductive health and HIV [accessed 21 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/408357/Making_it_work_revised_March_2015.pdf
  7. Surrey County Council (2016). Sexual Health Needs Assessment: Surrey 2015 [accessed 7 November 2016]. Available from: /dataset/sexual-health-needs-assessment-surrey-2015
  8. Department of Health (2013). A Framework for Sexual Health Improvement in England [accessed 7 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142592/9287-2900714-TSO-SexualHealthPolicyNW_ACCESSIBLE.pdf.
  9. Public Health England (2016). Infection Report Volume 10, Number 22. Sexually Transmitted Infections and Chlamydia Screening in England, 2015 [accessed 18 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/559993/hpr2216_stis_CRRCTD4.pdf
  10. Office for National Statistics (2014) Statistical bulletin: Conceptions in England and Wales: 2014 [accessed 21 February 2017]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/bulletins/conceptionstatistics/2014
  11. Public Health England (2016) A framework for supporting teenage mothers and young [accessed 21 February 2017]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/524506/PHE_LGA_Framework_for_supporting_teenage_mothers_and_young_fathers.pdf
  12. Department of Health (2015). Abortion Statistics, England and Wales: 2015 [accessed 21 February 2017]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/570040/Updated_Abortion_Statistics_2015.pdf
  13. Public Health England (2014). HIV in the United Kingdom: 2014 report [accessed 21 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/401662/2014_PHE_HIV_annual_report_draft_Final_07-01-2015.pdf
  14. NICE (2014). HIV Testing: local government briefing [accessed 9 February 2017]. Available from: https://www.nice.org.uk/guidance/lgb21
  15. RCGP Clinical Innovation and Research Centre (2013) Improving access to health care for Gypsies and Traveller, homeless people and sex workers [accessed 18 November 2016]. Available from: http://www.rcgp.org.uk/news/2013/december/~/media/Files/Policy/A-Z-policy/RCGP-Social-Inclusion-Commissioning-Guide.ashx.
  16. Department of Health (2013). Integrated Sexual Health Services: National Service Specification [accessed 7 November 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/210726/Service_Specification_with_covering_note.pdf

Signed off by

Members of the Sexual Health Expert Reference Group