Sexual Health Funding Proposals

SEXUAL HEALTH FUNDING PROPOSALS

NHS GRAMPIAN

2005 - 2008

Further to release of a sexual health strategy for ScotlandRespect and Responsibility, in May 2005 the Scottish Executive confirmed an allocation of £407,454 for 2005-2006, to take forward sexual health developments in Grampian.

Further to the submission of several funding applications, the Acting Director of Public Health pulled together a small group of senior NHS employees who met to decide on priorities for financial support. Given the finite nature of monies available, some difficult choices had to be made and the following criteria were used to guide the decision:

How proposals supported national and local priorities

Evidence of effectiveness of current provision

Effect on/integration with other services

Health benefit to the Grampian population

Effect on equity

Value for money

We were also guided by the Executive’s criteria for the clinical service plan to be submitted by the end of September 2005:

Demonstrable progress in frontline service provision

Intended outcomes, particularly around actions taken to reduce unintended teenage pregnancies and sexually transmitted infections and targeting those most at risk of sexual ill health

Measures to monitor and evaluate progress on outcomes and impact of new developments

Identified linkages with exiting services highlighting overall co-ordination of sexual health services across Grampian with particular reference to future service redesign

Regional networking/links with tertiary service providers

Contributions by voluntary/independent sector organisations

Further to this, the funding proposals outlined were taken back to the Grampian Sexual Health Strategy Group and NHS Grampian’s Operational Management Team (OMT) for approval prior to submission to the Executive.

After due consideration it was decided to support:

Genitourinary Medicine (GUM)

Square 13 the Sexual & Reproductive Health service (Family Planning)

Laboratory Services

Moray Community Health and Social Care Partnership SMS Young People’s Health ‘Drop In’ service

Primary Care

Needs assessment & evaluation to inform future planning

In addition to the Sexual Health Clinical Lead post which was as instructed by the Executive.

The financial breakdown of proposed spend of the £407,454 may be found on the Excel attachment. It was determined that to support the above bids was the most cost effective way of addressing the current problems of high demand being experienced by existing clinical services across Grampian, and allow expansion of same. Concurrently, it was determined that laboratory services must be prioritised in order to meet the increased workload as a result of the expected increased capacity at Genitourinary Medicine and the Sexual and Reproductive Health services. These services are well established and currently are under great pressure to meet demand. In addition, they are well integrated with other statutory and voluntary service providers, and this is developing further given the re-design of GUM and Square 13 Sexual and Reproductive Health and the advancement of the north of Scotland Sexual Health Managed Clinical Network (MCN).

Caledonia Youth, a sexual health service for young people less than 25 years of age, particularly those who are vulnerable, became newly established in Aberdeen early in 2005. A memorandum of understanding regarding service provision has been agreed by NHS Grampian as requested by the Scottish Executive. Whilst currently providing educational and counselling services, clinical services have not yet been developed. However, Caledonia Youth intend to deliver clinical services following a needs assessment of a cohort of young people, which has yet to be undertaken. Although it is recognised that Caledonia Youth could fill a gap relating to the provision of education, training, and counselling services, it was agreed, given the aforementioned criteria, Caledonia Youth could not be provided with financial support from the NHS Grampian allocation for sexual health clinical services at this juncture.

Sexual Health Clinical Services in Grampian

Additional Information Based upon Bids for Sexual Health Funds

September 2005

Sexual health service providers are working in close partnership to ensure the development and delivery of the Grampian Sexual Health Strategy. Those involved thus far include, Square 13 Sexual & Reproductive Health, Genitourinary Medicine (GUM), Public Health, General Practice, Craiginches Prison, Aberdeen City Community Health Partnership, Aberdeen University, 3 local authorities, and from the voluntary sector, PHACE Scotland Grampian Gay Men’s Health (&LGBT) Support Service and Drugs Action (sex industry workers component). In addition, Caledonia Youth’s recent arrival to Aberdeen has resulted in them being invited to join the strategy group.

The future will see the development of a North of Scotland Managed Clinical Network (MCN) and implementation of the strategy, with its wide ranging actions, via the Community Health Partnership structure. This will ensure continuing and improved partnership work and support for clinical and non-clinical activity, within and out with NHS Grampian, and therefore best use of existing and additional resources.

A joint specialist sexual health service is currently being developed, and although the physical location on one site within Aberdeen City will not be feasible until 2007/2008, there is already overlap of staff and provision between GUM and Square 13 led by the Consultant staff. Greater integration will occur in the development of the proposed additional posts via e.g. the Shared Care Partner Notification Service, and the Nurse Consultant post. Improving the sexual health skills base of clinical staff, throughout the community, such as those in primary care and school settings, via education and training, will ensure enhanced sexual health service provision across Grampian.

As instructed by the Executive, NHS Grampian has appointed a Lead Clinician for Sexual Health, Dr Gillian Flett, Consultant, Department of Sexual and Reproductive Health (Square 13), who will integrate sexual health services across Grampian. This will be achieved by utilising Community Health Partnership arrangements, and via close liaison with Susan Jappy, NHS Grampian’s Executive Director for Sexual Health and Acting Director of Public Health, Janet Bruce, Sexual Health Improvement Co-ordinator, and key service providers.

3. Genitourinary Medicine (GUM)

3.1 Current frontline clinical service provision

The Department of Genitourinary Medicine (GUM) is NHS Grampian’s specialist service for the prevention and management of sexually transmitted infections (STIs) and related conditions. GUM runs clinics in Aberdeen and Elgin and in 2004 conducted approximately 9,400 consultations, including 3,346 first time attendees (highest ever).

The average age of attendees is 28 but with a wide range (3 months to 75 years in 2004). People travel from all over Grampian to attend the GUM service although the majority of attendees come from Aberdeen and its hinterland.

Many people are seen from minority or disadvantage groups such as gay men, immigrants, and sex industry workers.

Fast track appointments are offered to those under 18 years of age and men who have sex with men.

The department works closely with primary care to improve management of STIs in the community particularly with regard to partner notification and advice on treatment.

Sexual health services re-design should help address capacity issues and further to this additional financial investment will improve service provision.

GUM nursing staff support Drugs Action in the provision of hepatitis A & B immunisation and general sexual health advice on a weekly basis.

3.2 Intended outcomes

Clearly increasing the staff capacity as proposed will have a direct impact on the number of patients GUM are able to offer appointments to and treat, as waiting times will be reduced.

Clinical sessions provided by the clinical assistant will increase from 2 to 5 per week. As 11 patients on average are seen in a session, this will mean an increase of 22 to 55 patients seen per week, an extra 33, allowing for 40 days leave approximates 2681 per year.

The F2 post will allow an additional 8 months of 5 clinics per week, or 1760 additional patients seen in a year.

The new Health Adviser through the shared care contact tracing service will follow up any additional positive tests thus increase testing and treatment of STIs.

Many patients require a chaperone therefore the increased Out Patient Assistant hours will allow a greater through flow of patients and reduce clinic delays experienced from waiting for a chaperone to be free.

It is estimated that the number of samples obtained will increase from approximately 6,000 per year to approximately 10,000 per year.

This should have an impact on the spread of STIs throughout Grampian.

Additionally:

Employment of a Health Adviser to establish an STI Shared Care Service would mean that GPs would be helped to perform partner notification without the patient needing to be referred to GUM. The amount of STI diagnostic work done in primary care has increased significantly in the last 5 years. For example, between 2003/4 and 2004/5 the Microbiology Laboratory saw an increase in specimens for testing coming from primary care by 10.6% for chlamydia and 8.7% for general STI testing. This has led to an increase in STI diagnoses in Grampian and has thus generated an increased requirement for partner notification. A sexual health survey of primary care (2005) indicated that only 18% of general practitioners offered contact tracing in addition to testing for chlamydia, and that GPs were keen to be supported with this. Currently when someone is diagnosed with an STI by his or her GP, the laboratory report advises referral for partner notification. In practice this happens infrequently. With the new service, when a patient gets a positive test result, GUM will be informed. If the GP has given prior consent then the patient will be contacted directly by a GUM Adviser so that partner notification can be undertaken. The Shared Care Service will limit the spread of STIs and improve partner notification in rural areas.

The bid for new nursing and medical staff will result in an increase in the amount of clinics offered and patients seen, therefore there is a need for additional Out Patient Assistant (OPA) hours for chaperoning and venesection. This is a cost-effective way of ensuring clinical support at an appropriate level and can also be useful in supporting the administration of the department. On-going service re-design and employment of additional staff will increase throughput of patients and additional OPA support will be necessary to support this. Current limited capacity means that when the OPA is on leave a higher level nurse stands in and thus operates well below her grade. If unavailable, the number of clinics offered is restricted.

The establishment of the new educational medical post (Foundation 2 post), producing 3 GUM experienced doctors per year, should encourage a pool of specialised staff within Grampian. Informal discussions lead us to believe that Grampian can offer an excellent teaching ground given the varied experience available, the enthusiasm of the infectious diseases physicians, dermatologists, gynaecologists and the regional speciality adviser.

The development of a Specialist Sexual Health Psychology Service is currently on hold pending the outcome of an exploration of existing services available in Grampian for patients experiencing significant and/or complex sexual health related difficulties such as people with HIV having difficulty coming to terms with the diagnosis or adhering to antiretroviral drug regimes, people suffering from the psychological sequelae of sexual assault, and obsessive/compulsive disorder related to sexual activity especially high-risk sexual behaviour.

3.3 Measures to monitor and evaluate progress on identified outcomes and impact of new developments

The effect on service capacity will be regularly monitored via the number of clinics, and patients seen, tested and treated.

Medical and nursing appointees will be appraised regularly.

The effect of the posts on the length of waiting times would be measured.

Shared Care Partner Notification Service will be regularly audited against key indicators such as the number of contacts seen per index case.

Foundation 2 doctor would have an educational supervisor and frequent appraisal. This would include observed consultations ands review of notes.

The programme and trainees would be assessed independently once per year.

After every few years the department will be assessed by the Speciality to ensure the maintenance of high quality standards.

4. Square 13 (Sexual & Reproductive Health)

4.1 Current frontline clinical service provision

Square 13 is the city centre base of the community sexual and reproductive health service for Grampian. The service sees around 21,000 patients a year for sexual health contraception, pregnancy advice, and chlamydia testing of young people. 1400 are seen for pregnancy advisory consultations across Square 13 and gynaecology. The current staffing level is two consultants, clinical medical officers (CMOs) and senior clinical medical officers (SCMOs).

The employment of an additional Consultant staff is in line with RCOG and Faculty of Family Planning Workforce Planning recommendations. The Scottish Committee of RCOG Workforce Planning document supports the establishment of one consultant post per 125,000 population. Grampian is unique within Scotland in that it also has responsibility for overseeing the provision of the abortion service, which is an additional responsibility

The established consultant posts are also different in that the consultants deliver some service from within gynaecology, which has advantages from a seamless care point of view. There are only two long-term funded consultant posts and further expansion is required. This would enable the provision of training to address the primary care needs highlighted by the 2005 sexual health survey, to support the public health dimension, particularly relating to supporting the NHS Grampian Executive Director of Sexual Health in the development of the North of Scotland MCN in sexual health.

The Consultant in Sexual and Reproductive Health has a much wider role than purely service delivery and an additional consultant is essential to support development of innovative approaches to address the identified sexual health needs in Grampian.
Currently, around 200 dedicated psychosexual patients are seen per year.

It is worthy of note that two small joint working groups have recently been established to address areas of identified need including exploring ways to:

Address the gap psychosexual/sexual dysfunction provision

Provide community STI testing of asymptomatic patients.

4.2Intended outcomes

The new posts will improve access to community based services in geographical locations convenient to the patient and thus devolve care out from the city resulting in increased capacity across Grampian.

Quality of care should be standardised and improved.

The development of care pathways should keep to a minimum the number of patients requiring onward referral to secondary care.

Expanded capacity in the area of sexual dysfunction, particularly in the provision of specialist expertise to support secondary referrals.

Reduced unintended pregnancy and STI rates.

Reduced rates of chlamydia should reduce rates of tubal factor infertility and ectopic pregnancy in the longer term.

It is estimated that the number of dedicated psychosexual patients seen would double to 400 over 3 years across all sectors.

Data collection has recently seen the establishment of an access system. The end of the calendar year therefore expects improved surveillance of all aspects of clinical provision such as type of clinic the patient was seen at, tests undertaken, advice given, contraception provided, referral for termination, who they were seen by, and whether they attended etc.

 Increased community STI testing of asymptomatic patients across Grampian.

It is estimated that an additional 3,000 - 5,000 patients across services would be seen over a 3 year period around general contraception, with the emphasis on the development of asymptomatic community STI testing throughout Grampian.

Additionally:

The establishment of an additional Consultant in Sexual and Reproductive Health would contribute to the leadership, support and development of a managed clinical network for the enhanced delivery of sexual and reproductive health in both community and primary care across NHS Grampian in liaison with NHS Highland.

The new Nurse Consultant Post in Sexual and Reproductive Health would support and develop nurse practitioner delivery of sexual and reproductive healthcare in community and primary care across NHS Grampian as part of a Managed Clinical Network. There is an already perceived gap at this service level and a similar successful post has been established in Lothian. The post has been under consideration for three years and is widely supported, with the only barrier to date being lack of funding. Increasingly, nurse practitioners are involved in the front line delivery of sexual health. Further development of nurse practitioners needs to be progressed in a planned ands co-ordinated way to ensure an appropriate skills mix is in place to expand capacity and deliver more effective sexual health care across the Grampian clinical network. The first step to inform developments will be an assessment of the sexual health educational and support needs of nurse practitioners across Grampian such as midwifes, school nurse, Health Visitors and Practice Nurses.

4.3 Measures to monitor and evaluate progress on identified outcomes and impact of new developments

Uptake of STI testing and infection, termination, uptake of hormonal contraception, and monitoring of rates of unintended pregnancy and STIs.

Quality of care can be measured against national standards where available.

5. Laboratory Services

5.1 Current frontline clinical service provision

The laboratories are currently working to full capacity and are seeing a year on year increase in workload of 10%, without any concurrent increased resources of staff, equipment or IT (interfacing). It has been difficult to maintain the service and there is no ‘slack’ available to absorb any new development.