sex and the city

Sex and the 2nd City

Liz AltayConsultant in Public Health

David WalkerHead of Sexual Health and Teenage Pregnancy

Commissioning

Sexual Health

• Sexual health and HIV a major public health issue

• UK has highest rates of poor sexual health in Europe

• Parts of Birmingham very high rates• Increasing STIs, HIV & terminations• Inequalities in sexual health• Preventable

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18

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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Syphilis

New HIV diagnoses

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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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Episode Year

Chlamydia

Gonorrhoea

Genital Herpes Simplex

Genital Warts

HIV and STI in Birmingham

Diagnosis rates of the five main STI diagnoses (GUM only) and HIV* in Birmingham residents, 1996-2011

A B

Source: HPA – West Midlands STI Surveillance Project; New HIV diagnoses data to end June 2011

Data provided by HPA West Midlands Regional Epidemiology Unit

* New HIV diagnoses data for 2011 not yet available

Please note that the above data does not include non-GUM chlamydia screening results

Acute STI diagnosis rates (GUM only) in Birmingham, West Midlands and England, 2009-2011

Source: HPA – Genitourinary Medicine Clinic Activity Dataset (GUMCAD)



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HoB Sth Bham BEN Birmingham West Mids England

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2009 2010 2011

Rates of acute STI diagnoses in Birmingham residents (GUM only) by age group and gender, January – December 2011

Source: Genitourinary Medicine Clinic Activity Dataset (GUMCAD)



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3500

<15 15-19 20-24 25-34 35-44 45+

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Age at start of episode

Female Male

Counts and rates of acute STI diagnoses in Birmingham residents (GUM only) by ethnic group and gender, January – December 2011



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Asian Black Mixed Other White Not specified

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Ethnic Group

Female Male

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Asian Black Mixed Other White

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Rates of acute STI diagnoses in West Midlands residents (GUM only) by PCT (graph) and local authority (map) of residence, January – December 2011

Date Prepared: 02/07/2012



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2010 2011

© Crown copyright and database right 2012. All rights reserved. Ordnance Survey Licence number 100016969/100022432

Rates of acute STI diagnoses in Birmingham (GUM only) by ward of residence, January – December 2011




Source: HPA –Survey of Prevalent HIV Infections Diagnosed (SOPHID)


Diagnosed HIV infected patients accessing care, West Midlands, 2010

Date Prepared: 02/07/2012

0 200 400 600 800 1000 1200 1400 1600

Birmingham

Coventry

Sandwell

Wolverhampton

Warwickshire

Stoke On Trent

South Staffordshire

Walsall

Worcestershire

Dudley

Shropshire County

North Staffordshire

Solihull

Telford And Wrekin

Herefordshire

Persons with diagnosed HIV accessing care

Prevalence of diagnosed HIV infection in adults (15-59 years), Birmingham, 2010

Source: HPA – Survey of Prevalent HIV Infections Diagnosed (SOPHID)



Source: HPA –Survey of Prevalent HIV Infections Diagnosed (SOPHID)


Diagnosed HIV infected patients accessing care by deprivation quintile, Birmingham, 2006 and 2010

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Deprivation Quintile

2006 2010

Most deprived Least deprived

Abortions

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15

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30All Age Abortion Rate 2010 : Source NCHOD

and Local TOPS data Source BSol BI

Birmingham local moving average 2008-10

Crude Rate per 1,000 Women aged 15-44

Abortion rate per 1,000 population aged 18-44 by PCT 2010

Abortions (Birmingham)

Mar

-08

May

-08

Jul-0

8

Sep-0

8

Nov-0

8

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep-0

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Nov-0

9

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Mar

-10

May

-10

Jul-1

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-11

Jul-1

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-12

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BPAS and Calthorpe activity trends - rolling 12 month totals

Under 18 18-24 yrs old 25-34 yrs old 35 yrs old +

For the 12 months ending

Teenage Conception Rate per 1000 Females 15-17 years

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Teenage Conception Rates

Birmingham West Midlands England 2010 Target

Source: Birmingham and Solihull Business Intelligence

Number of Teenage Conceptions per 1000 Population Females aged 15-17 between April 2007 and March 2010 by Ward

Source: Bham and Solihull Business Intelligence 2012

Sexual Health Service Delivery

in the 2nd city

Chlamydia Screening Programme

Young Peoples Services

Reproductive Sexual Health Services

Specialist HIV Treatments

Genito-Uriniary Services

Teenage Pregnancy Services

Third Sector HIV Services

Termination of Pregnancy Services

Sexual Health Promotion Services

Level 1 – Oral contraception. Condoms. EHC. Sexual Health Promotion. Abortion referral. Vasectomy referral. Full sexual health history and assessment. Screening of asymptomatics for chlamydia and gonorrhoea (GC+ve ref to level2. HIV Testing / ongoing shared care with level 3

Level 2 – Symptomatic & asymptomatic STI’s. Partner notification. LARC provision

Level 2 – services also provide services as outlined in level 1

Level 2 – Psychosexual therapies

Level 3 – Investigation and management of complex STI’s, HIV complex contraception needs due to other illness. Termination of pregnancies. Vasectomy.

Specialist Sexual Health Promotion

Level 3: investigation and management of complex STIs, HIV complex contraception needs due to other illness. Termination of Pregnancies.

Vasectomy.

Specialised Sexual Health Promotion

Level 2 - symptomatic & asymptomatic STIs. Partner notification. LARC provision

Level 2 services also provide services as outlined in level 1

Level 1 – Oral contraception. Condoms. EHC. Sexual health promotion. Abortion referral. Vasectomy referral. Full sexual health history and

assessment. Screening of asymptomatics for chlamydia and gonorrhoea (GC +ve ref to level 2). HIV testing/ on going shared care with level 3

NB All services to provide SH promotion.

Example of integrated service delivery

. Psychosexual therapies.

Sexual Health in the 2nd City - What has been achieved?

• 10 year national strategy – sexual health , teenage pregnancy, HIV Commissioning – understanding need + local SH strategy

• New programmes /partnerships – Teenage pregnancy

• NHS Performance framework – KPIs : access to terminations , teenage conceptions and chlamydia

• Real growth in range , type , quality of service provision

• Increased funding – from £8.78 million [ 2006 ] to £ 20 million plus]

• Real Improvements in sexual health outcomes

Sexual Health in the 2nd City - What has been achieved?

25.7% reduction in Teenage conception rates December 1998 and June 2012 cf West Midlands (19.4%) : England (20.3]

Chlamydia screening coverage [ 15 – 24 yrs ] 29 %- 33% cf national average - 25.2 %

50% decline in Gonorrhea rates - 10 years

Sexual Health in the 2nd City - Challenges :

• Inequalities in sexual health persist

• Distribution of services - not rational /needs led

• Quality and range of primary care services – v .variable

• Balance of investment [ GUM ] – “downstream “ not prevention

• Service provision – separate , parallel , fragmented

Sexual Health in the 2nd City – Determinants of sexual health

• Social deprivation • Ethnicity • Migration • Culture• Service provision + access • Neighbourhoods

Opportunities:

Focus on Social Determinants of Health

Move away from ‘Deficit’ model of delivery to an ‘Asset ‘ model of delivery

• Deficit model – focuses on failure of communities to avoid disease

• Asset model - focuses on the potential to create and sustain health

Opportunities:

Focus on Social Determinants of Health

How ?

• As an employer

• Through the services commissioned and delivered

• Through regulatory powers

• Through community leadership

• Through localism

• Any others?

Sexual Health System• Health Improvement (Public Health lead)

• Strategy/Policy• Reducing SH inequalities• Sexual Health promotion/prevention

• Health Protection (HPA lead)• Surveillance• Epidemiology• Outbreaks

• Sexual Health Service Improvement (Public Health/NHS Cluster)• Commissioning effective services• Audit & evaluation• Clinical Governance

Current commissioned servicesLevel 3 Genito-urinary medicine (GUM)

HIV treatment and careComplex contraceptive services(provided by acute trust)

Specialist services

Abortion services – acute trusts and Independent Sector.

Psychosexual service

Sexual Assault Referral Centre (SARC)

Level 2 Integrated, community based contraceptive and sexual health services x 2 ClinicsBrook (Young People Focused)GP enhanced, open access services – 2 clinicsGP provision of coil and implants

Level 1 GMS/PMS GP servicesChlamydia screening programmeCommunity pharmacy servicesHealth promotionTeenage Pregnancy programmes

Sexual Health Responsibilities

• LAs will be mandated to commission open access STI testing & treatment and contraception services for all persons present in their area. LAs will commission needs-led sexual health services for its population. The commissioning responsibility will involve holding the ring for an integrated sexual health system, core functions

include: – comprehensive needs assessment; – strategy development– sexual health promotion, particularly with high risk groups– health protection in the form of surveillance, epidemiology and the

management of outbreaks; – provision of partner notification; – targeted services, including outreach work for high risk groups;– procuring high quality accessible integrated sexual health services; – workforce planning in partnership with training consortia;– monitoring sexual health outcomes.

PHOF Outcomes

• Chlamydia diagnoses (15-24 year olds)• Reduction in people presenting with HIV at a

late stage of infection• Reduction in teenage conceptions in under

18’s• Indirectly related outcomes:

• ante-natal HIV screening• Violent crime (including sexual violence)• Employment for those with a long-term health

condition including those living with HIV

Local Authorities will commission Clinical Commissioning Groups will commission

NHS Commissioning Board will commission

Comprehensive sexual health services, including:

Contraception, including LESs (implants) and NESs (intrauterine contraception) – but excluding contraception provided as an additional service under the GP contract)

STI testing and treatment, including post-exposure prophylaxis after sexual exposure, chlamydia screening as part of the National Chlamydia Screening Programme and HIV testing

Sexual health aspects of psychosexual counselling

Any sexual health specialist services, including young people's sexual health and teenage pregnancy services, outreach, HIV prevention and sexual health promotion work, services in schools, colleges and pharmacies

Fully integrated and comprehensive termination of pregnancy services – [but there will be a further consultation about the best commissioning arrangements in the longer term]

Sterilisation

Vasectomy

Contraception provided as an additional service under the GP contract

HIV treatment and care [although work is continuing to determine whether CCGs should commission some elements of the pathway]

Promotion of opportunistic testing and treatment for STIs and patient requested testing by GPs

Sexual Assault Referral Centres

1st April 2013Level 3 Genito-urinary medicine (acute trust)

HIV treatment and careComplex contraceptive services(provided by acute trust)

Specialist services

Abortion services – Acute trusts and Independent Sector

Psychosexual service

Sexual Assault Referral Centre (SARC)

Level 2 Integrated, community based contraceptive and sexual health services:BrookGP enhanced, open access services – 2 clinicsGP provision of coil and implants

Level 1 GMS/PMS GP servicesChlamydia screening programmeCommunity pharmacy servicesHealth promotionTeenage Pregnancy programmes

Sexual Health Commissioning OptionsService Provider Current

Commissioner LAs Contract

Support Clinical Governance

Commissioner post April 13

Contract Support April 13

GUM NHS Trust BPH Birmingham,Solihull Sandwell,Dudley Walsall

BSol NHS Cluster

BSol NHS Cluster

PH in Local Authority

CSS

HIV Treatment NHS Trust NHS Specialised commissioner

West Midlands NHS Specialised commissioner

NHS Specialised commissioner

NHS CB withPH support via core offer

NHSCB/CSS

Integrated Sexual Health Services

NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local Authority

CSS

Brook (Young People) 3rd sector BPH Birmingham & Solihull

BPH BSol NHS Cluster PH in Local Authority

LA

Chlamydia Screening (under 25s)

NHS Trust BPH Birmingham & Solihull

BSol NHS Cluster BSol NHS Cluster PH in Local Authority

CSS

Reproductive Sexual Health Services (Contraception)

NHS Trust BPH

Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local Authority

CSS

Sexual Health Promotion/Training


CSS

Termination Services 3rd sector BPH

Birmingham Solihull Shropshire

BPH BSol NHS Cluster CCGs with PH support via core offer

CSS

Enhanced primary care services

GPs Pharmacies

BPH Birmingham Cluster Primary Care Commissioners

BSol NHS Cluster PH in Local Authority (via NHS CB?)

NHS CB

HIV Prevention Services 3rd sector BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local Authority

LA

Psycho-sexual counselling


CSS

Teenage Pregnancy programmes/services

NHS Trust BCC Pharmacies 3rd sector

BPH Birmingham BSol NHS Cluster Primary Care BPH

BSol NHS Cluster PH in Local Authority

LA & CSS

SARC To be tendered BPH Birmingham,Solihull Walsall,Wolvs,Dudley

BSol NHS Cluster

BSol NHS Cluster

NHS CB with PH support

NHSCB/CSS

Proposal

• Policy/Strategy – PH core team (LA) & PHE

• Needs assessment – PH core team (LA)

• Sexual Health Improvement/prevention activity – PH core team (LA)

• Sexual Health inequalities – PH core team (LA)• Health protection (surveillance, outbreaks, epidemiology)– PHE with

oversight from DPH through Birmingham HP Forum

• Strategic commissioning of sexual health services – PH core team

– Contract Support for NHS Services – CSS (including Clinical Governance)

– Contract Support for non NHS Services – LA (including clinical governance)

•Strategic commissioning advice and support to NHS CB and CCGs – PH core team (LA) through “core offer”

sex and the city

Health & Medicine