NHS BUCKINGHAMSHIRE
SEXUAL HEALTH
& HIV STRATEGY
2009-2014
(REVIEWED AND UPDATED SEPTEMBER 2011)
1
2
Foreword
Good sexual health is a vital aspect of health and well being and it is important that
people have the right information, confidence and the means to make the right
choices for themselves. Promoting sexual health is about enabling people to
develop safe and positive relationships.
NHS Buckinghamshire has published this 2009 – 2014 strategy to improve the health
of the local population and reduce inequalities. This will be done by commissioning
integrated sexual health services of a high quality that meet the sexual health needs
of the local population and are equitable, cost effective and engage relevant
community groups in their development.
Over the last two years, a huge amount of work has gone in to implementing a sexual
health programme of work in Buckinghamshire and some of the key achievements
are highlighted below:
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providing additional access to contraceptive services in further and higher
education settings
setting up a long acting reversible contraception (LARC) training programme
for general practitioners to improve access to contraception
recommissioning of a termination service including early medical abortion
commissioning a new sexual assault referral centre with other NHS
organisations across the Thames Valley
issuing a tender for a new level two integrated (STI screening and
contraception) sexual health service
development of a local sexual health website –
www.sexualhealthbucks.nhs.uk
roll out of the county wide emergency hormonal contraception scheme in
community pharmacy
improving access to condoms in non statutory youth and community settings
achieving prompt access to local genitourinary (GUM) services within 48
hours.
It is key, in light of future NHS changes, we continue to work across the NHS, local
authorities and with third sector organisations to improve sexual health and make a
positive difference to the lives of people in Buckinghamshire.
Dr Jane O’Grady
Director of Public Health
NHS Buckinghamshire
3
Acknowledgements
The development of this strategy would not have been possible without the valuable
contribution made by all stakeholders in the local sexual health economy, especially
those linked into the local Sexual Health Network in particular, Janette Harper,
Commissioning Portfolio Lead, Angie Blackmore, Public Health Principal and Jenny
Kent, Public Health Practitioner at NHS Buckinghamshire.
4
Contents
Foreword ............................................................................................................... 3
Acknowledgements ................................................................................................ 4
Contents ................................................................................................................ 5
Executive Summary ................................................................................................ 6
Glossary ................................................................................................................. 9
Purpose of the Strategy ........................................................................................ 10
Strategic Vision .................................................................................................... 11
Setting the Scene.................................................................................................. 12
Buckinghamshire Sexual Health Network ............................................................. 14
National Sexual Health Policy Targets and Indicators ............................................ 14
Buckinghamshire’s Current Performance Against Key Targets ............................... 15
Sexual Health Profile ............................................................................................ 15
Local Sexual Health Services (2009) .............................................................................. 17
GUM & Sexual Health Services ..................................................................................... 18
Contraceptive Services................................................................................................. 20
Community Pharmacies ............................................................................................... 22
Chlamydia Screening Programme ................................................................................. 23
HIV Services ................................................................................................................ 24
Termination of Pregnancy Services............................................................................... 26
Vasectomy and Sterilisation ......................................................................................... 27
Psychosexual Services and Erectile Dysfunction ............................................................ 28
Sexual Assault & Exploitation ....................................................................................... 29
Sexual Health Promotion ............................................................................................. 30
Patient and Public Engagement ............................................................................ 32
Sexual Health Strategic Aims and Priorities........................................................... 33
Local Health Inequalities .............................................................................................. 33
Strategic Aims ............................................................................................................. 33
Priorities ..................................................................................................................... 34
References & Bibliography ................................................................................... 38
Appendices .......................................................................................................... 39
Appendix 1: Terms of Reference for the Sexual Health Network ................................... 39
Appendix 2: Levels of Sexual Health Service Provision .................................................. 40
Appendix 3: Sexual Health Guidance Documents .......................................................... 42
5
Executive Summary
The continued rise of levels of sexually transmitted diseases, terminations and
unplanned pregnancy both nationally and locally demonstrate that there is a need for
a continued drive to address risky sexual health behaviours through education and
access to services.
As the number of people living with HIV, and living longer with HIV, continues to grow,
the demand for flexible services to meet the needs of people living with this long term
condition also rises.
Since the publication of The National Strategy for Sexual Health and HIV in 2001
there has been an increased drive and focus on addressing sexual ill health,
especially in the prevention of sexual ill health and unplanned pregnancy. Addressing
sexual ill health has been shown to be cost effective, both in terms of the prevention
of onward transmission and timely treatment of illness to prevent further co
morbidities, and in terms of patient outcomes related to quality and control of their life.
The key challenges within sexual health locally continue to be:

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Reducing rates of sexually transmitted infections (STIs), especially
chlamydia in young people under 25
Reducing late diagnosis and undiagnosed sexually transmitted infections
including HIV, especially in high risk groups
Improving access to contraception to reduce unintended pregnancies
Reducing the under 18 teenage conceptions leading to an abortion
The objectives of the previous sexual health strategy for Buckinghamshire1 continue
into this strategy and include:
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

1
To raise public awareness of sexual health services and the importance of
positive sexual and emotional relationships, and risks of unsafe sex.
To increase access to sexual health information, treatment, support and
advice, especially to young people and other high risk groups.
To provide skills and build capacity in individuals and communities,
especially young people, to enable them to take greater control over their
sexual health by gaining key relationship skills such as:
- Negotiating for safer sex
- Better communication
- Assertiveness, being able to say ‘no’ to sex
- Enhancing self-esteem in individuals, groups and communities so
that they are able to make informed decisions about their sexual
health.
Mid-South Buckinghamshire Sexual Health & HIV Prevention Strategy 2006-2009
6
Progress has been made in many of the areas covered in the previous strategy,
including:
 Introduction of level 2 community sexual health services to increase
access to STI testing & treatment
 Increase in the provision of Emergency Hormonal Contraception (EHC,
also known as “the morning after pill”) via community pharmacy
 Introduction of a Chlamydia Screening Programme locally
 Introduction of a condom distribution scheme for young people
 Piloting of You’re Welcome standards for developing young people
accessible services.
The higher rate of under 18 conceptions leading to a termination and late diagnosis of
HIV, suggest that more work is still needed to increase awareness, access and
education around all aspects of sexual health.
The previous strategy was young people focused, whilst this strategy has been
developed to consider the needs of all communities within the local population. The
strategy has been developed based on national strategies, a refreshed local sexual
health needs assessment and local priorities. A multi-disciplinary approach has
ensured that all stakeholders have been able to contribute to this strategy, and will
continue to be the approach taken to develop local pathways based on national
evidence and designed to address local health inequalities.
Since the development of this strategy, progress has been made in a number of
areas including:
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The achievement of the GUM 48-hour offered target (offering an
appointment within 48 hours of client’s first contact) for the first time in
Buckinghamshire
Commissioning a pilot service offering contraception alongside the level 2
outreach sexual health clinics
The commissioning of a young people’s drop in service in the south of the
county
The refocusing of the Chlamydia Screening Programme to embed
chlamydia screening into core services
The retendering of termination services to increase the value achieved
from this service and increase local access
Commissioning a new sexual assault referral centre (SOLACE)
Development of a local specialist training programme (LARC)
Development of local primary care training programmes around sexual
health
Development of a standardised service specification across providers of
GUM services
Review of specialist contraception services to look at options for future
service development
Introduction of Chlamydia Screening via local community pharmacies
Development of a local sexual health website
7
Work has also begun in the following areas:


Joint review of HIV services with the council
Review of level 2 sexual health services post the contraception pilot
This strategy aims to provide a focus for all local providers and stakeholders to use to
work towards quality, integrated, holistic sexual health services that are patient
focused and meet the needs of all those living within Buckinghamshire.
8
Glossary
AIDS
ASG
BASHH
BCC
bpas
CaSH
CSW
C-Card
CSP
DH
EHC
EMA
FPA
FRSH
GMS
GP
GUM
HIV
HPV
ISVA
LARC
LINk
LGBT
MedFASH
MSM
NICE
PCT
PMS
SARC
SHA
SHAW
STI
ToP
TVPS
Acquired Immune Deficiency Syndrome
AIDS Support Grant
British Association for Sexual Health and HIV
Buckinghamshire County Council
British Pregnancy Advisory Service
Contraceptive and Sexual Health Service
Commercial Sex Workers
Condom Distribution Scheme
Chlamydia Screening Programme
Department of Health
Emergency Hormonal Contraception (also known as the “morning after
pill”)
Early Medical Abortion
Family Planning Association
Faculty of Reproductive and Sexual Health
General Medical Service contract (for provision of primary care
services)
General Practice/ General Practitioner
Genito-Urinary Medicine (Specialist clinics for the treatment of STIs)
Human Immunodeficiency Virus
Human Papilloma Virus
Independent Sexual Violence Advisor
Long Acting Reversible Contraception (e.g. coils and implants)
Local area Involvement Network
Lesbian, Gay, Bisexual and Transexual people
Medical Foundation for AIDS & Sexual Health
Men Who Have Sex With Men
National Institute for Health and Clinical Excellence
Primary Care Trust
Primary Medical Services contract (for provision of primary care
services)
Sexual Assault Referral Centre
Strategic Health Authority
Sexual Health At Wycombe (GUM clinic)
Sexually Transmitted Infection
Termination of Pregnancy
Thames Valley Positive Support
9
Purpose of the Strategy
Sexual ill health costs the NHS more than £700 million a year (HPA, 2004). For
individuals this ranges from brief discomfort to pelvic inflammatory disease, infertility,
and in some cases, death as a result of HIV / AIDS.
Sexual health is a state of physical, emotional, mental, and social well being in
relation to sexuality; it is not merely the absence of disease, dysfunction or
infirmity. 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.
(WHO, 2002)
The purpose of this strategy is to bring together all services within the sexual health
economy and align them strategically to produce integrated holistic sexual health
services for the population of Buckinghamshire.
The strategy will outline NHS Buckinghamshire’s strategic vision for services and look
at the progress of sexual health services since 2009. It specifically looks at sexual
health service provision and promotion, linking with other local and national strategies
where appropriate2. Other areas, such as the HPV vaccine programme, the various
cancer screening programmes, fertility, and gynaecological issues, whilst linked to the
area, are out of scope for this strategy and are therefore not covered here.
This strategy has been developed in consultation with all stakeholders within the
sexual health economy of Buckinghamshire to ensure it is a comprehensive strategy
that all parties can engage in to deliver the strategic vision for sexual health services
within Buckinghamshire.
Buckinghamshire Sexual Health Network will use this strategy to guide the
development of services locally across the local health and social care economy.
2
E.g. the local Teenage Pregnancy Strategy 2009-2011 (Bucks County Council) and Alcohol
Harm Reduction Strategy (2004, Prime Minister’s Strategy Unit). See References and
Bibliography section for details.
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Strategic Vision
The strategic vision for sexual health services across Buckinghamshire was
developed with key stakeholders in the sexual health economy of Buckinghamshire at
a Visioning Event held with the support of the DH National Support Team for Sexual
Health. This vision represents an ideal statement that stakeholders should work
towards and will be the focus for developments in sexual health services across
Buckinghamshire.
The Vision for Sexual Health Services in Buckinghamshire:
To provide holistic, confidential, integrated sexual health services that work
through local partnerships, and that act as a centre of excellence for quality,
training and clinical governance issues;
To have pathways that provide equitable access to the full range of sexual
health services [including abortion] through a central hub and are supported
by prevention, outreach and signposting;
That services are delivered by the most appropriately trained staff to meet
the needs of our local population and in particular those identified as most
vulnerable – as informed by local evidence and user involvement;
And that sexual health services are transparently commissioned, well
marketed and cost-effective.
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Setting the Scene
NHS Buckinghamshire has set itself four strategic objectives that underpin the
commissioning plans and direction for the organisation. These are:
1) Improve the health status of our local population and reduce inequalities
in health
2) Enhance quality and safety of patient services that we commission
3) Enable local people to have a greater influence on services that NHS
Buckinghamshire commissions and increase the ability of people to
manage their own care
4) Achieve financial sustainability with headroom to invest
These are reflected in the core values and guiding principles that support the
development of this strategy and its implementation:

Equality – especially for vulnerable groups who are more likely to experience
poor sexual health, targeting services where needed to ensure equitable
access to sexual health services and reduce sexual health inequalities.

Collaborative Working – partnership working with key stakeholders is vital to
ensure that services are integrated and target where they are needed most,
without duplication and with clear pathways between services.

User Involvement – information from consultations, service user feedback
and the development of a range of different ways to enable public and user
involvement in service development to ensure that services meet local needs.

Choice – to support the public to engage in their own sexual health and
wellbeing access to services and information must be available through a
range of different media and settings across the county.

Quality – all services and information need to meet with national standards
(including standards around respect and confidentiality), and be evidence
based to ensure that services meet the needs of the local population and
maximise the use of available resources appropriately.
12
The National Strategy for Sexual Health and HIV (2001) provides the strategic
direction for improving sexual health in England. It includes five key aims which are
reflected in local commissioning priorities:
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Reduce transmission of HIV and STI’s
Reduce prevalence of undiagnosed HIV and STI’s
Reduce unintended pregnancy rates
Improve health and social care for people living with HIV
Reduce stigma associated with HIV and STI’s.
Overall, the direction of the National Strategy is working towards achieving:
 Better prevention
 Better services
 Better commissioning
Much of the available guidance supports the need for all health services, including
sexual health and HIV services, to engage in keeping people healthy (prevention of
poor sexual health), rather than just treating illness.

Levels of HIV and STIs continue to rise across the UK, with numbers of new
diagnoses up 63% since 1998. The cost of providing sexual health services,
including contraception and abortion services is now in excess of £0.25 billion
each year nationally.

Advances in treatment mean people with HIV are able to live healthier lives for
longer, but this also increases the costs of treatment and care for HIV, which
is now estimated to cost around £0.5 billion a year in the UK. In the National
Sexual Health and HIV Strategy3, the DH also estimates that the socioeconomic costs of HIV are increasing by up to £3 billion each year.

Research published by the fpa in 20054 indicated that the NHS in England
could save almost £1 billion over 15 years by investing in contraception
services and speeding up access to abortion by just ten days.
The effective prevention of HIV and STIs and investment in contraception services is
essential to reduce transmission and limit costs.
NHS Buckinghamshire commissioned a refresh of the Sexual Health Needs
Assessment for Buckinghamshire in 2009 to support the development of this strategy.
This sexual health population profile has been refreshed in 2011 to provide an
updated picture of the local population needs to ensure that services continue to
develop to meet local needs.
3
The National Strategy for Sexual Health and HIV, DH, 2001
4
The Economics of Sexual Health, 2005, FPA
13
Buckinghamshire Sexual Health Network
The Buckinghamshire Sexual Health Network5 has been established as a forum to
bring together the key stakeholders in the local sexual health economy to address
local needs and drive forward national and local agendas around sexual health6.
The Buckinghamshire Sexual Health Network7:
 Aims to facilitate equitable, co-ordinated and integrated sexual health services
for the local population
 Has responsibility for developing and reviewing the progress of projects in
relation to the local sexual health priorities and plans
 Is chaired by Public Health, NHS Buckinghamshire and meets quarterly.
 Comprises of all local sexual health service providers, local community and
voluntary sector organisations, and statutory services (such as local authority
and health), with membership reviewed annually
 Invites other agencies and stakeholders to the group to ensure that links are
developed and maintained with related areas/ specialities
 Establishes sub-groups from within the Network to work on key projects.
National Sexual Health Policy Targets and Indicators
Since the development of the National Strategy for Sexual Health (2001), and the
review of the National Sexual Health Strategy by MedFASH8, there have been a
number of national and regional targets and indicators developed to improve the
performance of sexual health services.
The table overleaf outlines Buckinghamshire’s performance against these targets for
2008-09, 2009-10 and 2010-11. With the current redesign of health and social care
services under the coalition government, these indicators are currently under review
and are likely to change from 2012-13. Once the new targets and indicators have
been decided upon services will be assessed and developed where necessary to
meet the new targets.
5
Previously called the Buckinghamshire a Sexual Health & HIV Strategy Group
This is in line with recommendations in the national sexual health strategy to support
providers to work together to deliver equitable, holistic care and focus on sexual health
promotion to reduce STIs, HIV and unintended pregnancies.
7 Please see appendix for details of the Terms of Reference
8 Progress and Priorities – working together for high quality sexual health, 2008, MEDFASH
6
14
Buckinghamshire’s Current Performance Against Key Targets
Bucks Performance9
National Targets
2008-09
2009-10
2010-11
Increase the proportion of patients
offered a GUM appointment within 48
hours of them first contacting the service
to 98%10
Increase the proportion of patients seen
within GUM services within 48 hours to
85%.
17% under 15 to 24 year olds to be
screened for Chlamydia in 2008/09
increasing to 25% and 35% in
subsequent years.
Total
Offered
92.3%
Total
Offered
98.1%
Total
Offered
99.9%
Total Seen
76.9%
Total Seen Total Seen
83.9%
82%
15 to 24
year olds
screened
8.3%
15 to 24
year olds
screened
10.4%
15 to 24
year olds
screened
10.3%
Teenage pregnancy - reduce the under
18 conception rate by 50% by 2010.
(Note that the local target is to reduce
rates by 45% due to the lower than
national average rates of teenage
pregnancy in Bucks).
Conception
in under 18
year olds
for 2007 =
236 (nos)
Conception
in under 18
year olds
for 2008 =
240 (nos)
Conception
in under 18
year olds
for 2009 =
234 (nos)
Rate is 23.9
Data is always 16 months in arrears to
per 1000
account for conceptions that go on to live female
births.
population
aged 15-17
years old11
Rate is
24.4 per
1000
female
population
aged 15-17
years old
Over 99%
in local
hospital
maternity
units
Rate is
24.2 per
1000
female
population
aged 15-17
years old
Over 99%
in local
hospital
maternity
units
An increase in the proportion of pregnant
women accepting an antenatal HIV test.
Over 99%
in local
hospital
maternity
units
Sexual Health Profile
Sexual Health in Buckinghamshire: a review (2009) provides a refreshed sexual
health needs assessment for Buckinghamshire, with the population information being
further update by Sexual Health in Buckinghamshire PCT: Population Profile and
Service Activity, 20111213, with details of the national and local picture of sexual
health.
9
Data taken from Sexual Health Needs Assessment 2009, the Sexual Health Population
Profile, 2011 and the latest available ONS and HPA data.
10 Note there is a 2% tolerance with this target
11
1998 baseline: 223 conceptions/Rate of 24.8 per 1000 female population aged 15-17 years
12
This can be found on the www.sexualhealthbucks.nhs.uk website.
15
Buckinghamshire Sexual Health Profile

The number of people living with HIV in Buckinghamshire more
than doubled (from 119 in 2002 to 338 in 2009) over the last 7
years of available data

Although the numbers of new diagnoses of HIV are decreasing, up
to 40% of all these cases are diagnosed late in the disease
progression, meaning the risks of complications and the health
burden are higher for these individuals

Chlamydia remains the most commonly diagnosed STI

New cases of gonorrhoea and syphilis are small, with cases of
gonorrhoea decreasing from 2001

Buckinghamshire has a significantly lower teenage pregnancy rate
for under 18s (24.2 per 1,000 females aged 15 – 17) compared to
the England rate of 38.2

A higher percentage (61%) of under 18 conceptions end in
termination compared to 51% and 50% in the South East and
England respectively

Termination and repeat termination rates in Bucks are in line with
regional and national averages

A number of sexual health inequalities exist across
Buckinghamshire, including:
-
Lack of outreach services to engage with MSM (men who
have sex with men) who are a high risk group for sexual ill
health and discrimination
-
Lack of out-reach services to minority ethnic groups,
especially around HIV infection
-
Young people locally feel under pressure to have sex, and
almost a quarter report not knowing where to go for sexual
health information and advice
-
No local sexual health promotion programmes in place for
Commercial Sex Workers
-
Limited or no sexual health promotion programmes for
vulnerable groups, including LGBT community, people with
learning disabilities, substance mis-users and offenders.
13
Both documents where commissioned by Public Health and provided in conjunction with
Solutions for Public Health.
16
Local Sexual Health Services (2009)
The map below demonstrates the current arrangement of services (as of 2009) and
areas of deprivation. This demonstrates the need to review access to services to
ensure equitable access across Buckinghamshire and to ensure that services are
targeted to the areas of need. Details of local services and plans to develop these are
outlined below.
Sexual Health Services and IMD 2007 score in NHS Buckinghamshire, 2009
17
GUM & Sexual Health Services
In Buckinghamshire access to sexual health testing and treatment services is
available from a range of providers:



Specialist GUM level 314 services are provided in Aylesbury at the Brookside
clinic and High Wycombe at the SHAW clinic. These clinics are now both
provided by Buckinghamshire Healthcare NHS Trust15
Level 2 sexual health testing and treatment services are provided by The
Practice and the Kestrel service at a variety of locations across the county
Residents in the south of the county also often cross into East Berkshire to
access GUM at The Garden Clinic, Slough which offer holistic walk-in clinics
providing STI testing and contraception including LARC, and specialist clinics
for LARC, HIV, and Sexual Dysfunction.
In 2006 the Department of Health introduced a national target to improve access to
GUM16 to reverse the recent trend of a rising spread of sexually transmitted diseases
across the country:


By March 2008, all patients who made contact with a GUM service to be
offered an appointment within 48-hours of making initial contact
Regionally a target of 85% of patients contacting GUM services being seen
within 48 hours was introduced at the same time.
Level 2 services where introduced in 2006 to support achievement of these targets
locally by increasing capacity and providing community provision for sexual health
testing and treatment. These are provided in a range of community settings across
the county including GP surgeries, community hospitals, colleges & universities and
drop-in centres.
Both levels of service will be developed in line with DH Best Practice Guidance about
reaching and maintaining the 48-hour access target17, with key priority given to:





The improved use of resources to enable clinics to be run in the evenings,
early mornings and at weekends
Ensuring choice of access by offering a choice of both walk-in and
appointment
Promoting informed choice to balance the public health risks of delayed
attendance with patient choice (through encouragement of patients to attend
as soon as possible)
Making use of outreach facilities to reduce barriers such as travelling time to
attending services, especially in specific high risk communities
The appropriate delivery of services across a sexual health network to ensure
the needs of all sectors of the community are met.
14
Details of the different levels of service as defined by MedFASH & BASHH can be found in
the appendices.
15 Since 2010/11.
16
National Support Team for Sexual Health, DH, (2006), 10 High Impact Changes for
Genitourinary Medicine 48-Hour Access, London, DH
17
National Support Team for Sexual Health, DH, (2008), Genitourinary Medicine 48-hour
Access: Getting to target and staying there, London, DH.
18
Key Service Issues & Priorities (as of 2009):
- GUM & Level 2 Sexual Health Services

To review service design to ensure that capacity is in place and
efficiently utilised to enable sustaining of the 48-hour offered target
(achieved for the first time in 09/10)

Review the patient pathway for access to GUM/STI services to
ensure there is clear alignment between providers to ensure
patients are seen by the most appropriate service

Develop outreach services to engage with vulnerable groups and
support access to services across the county to meet the needs of
the local population and address health inequalities

Investigate the feasibility of developing out of hours clinics for GUM,
including later evening clinics and weekend access within county

Standardise service specifications across both GUM clinics to
ensure equitable access to services

To re-engage GUM with the prison health provider to ensure that
services are available to this population

To engage with patients and the local population to ensure that the
GUM and STI services are patient focused

Review services simultaneously with family planning/contraception
service to ensure a coherent approach to contraception and sexual
health services for all patients

Investigate options for the provision of integrated sexual health and
contraception services in line with national and local drivers

To develop targeted services, clinics and campaigns (including outreach) to key high risk groups, such as Men who have Sex with
Men (MSM) and Commercial Sex Workers (CSW).
19
Contraceptive Services18
Specialist Services
The specialist contraceptive services in Buckinghamshire are provided by
Buckinghamshire Healthcare NHS Trust since the merger of the PCT provider arm in
2010.
The CASH service (Contraception and Sexual Health Service) provides clinics from
the Brookside centre in Aylesbury, High Wycombe and a weekly clinic in Chalfont St
Peter which include:






Weekend and evening clinics
All forms of contraception including LARC
Dedicated young people’s clinics
Appointment and walk-in services
Emergency contraception including emergency coil fits
Advice, guidance and treatment for complex cases.
There is an urgent need to review the current service design and role of the CASH
service to ensure that the service is robust and fit for purpose as a specialist level 3
provider of contraception across the county, including the provision of training for
other non-specialist providers of contraception. The current clinic arrangement is
based on historic set-up, which has at times resulted in huge pressures on the service
and does not make best use of available resources, occasionally resulting in some
temporary clinic closure.
GP Services
All of the Buckinghamshire GP practices provide basic contraceptive services under
the current GMS and PMS contracts, which includes:
 Advice about the full range of contraceptive methods available
 Advice about sexual health promotion and STIs
 Testing for specific STIs in symptomatic patients and referrals as necessary
for specialist sexual health services
 Prescribing of contraceptives
 Provision of LARC methods where specialist training has been undertaken in
line with NICE guidance.
There is concern that sexual health service provision within General Practice is
variable and often dependent on the training and skills of GPs and Nurses within the
practice. Approximately 75% of women go to their GP for contraception; therefore it is
essential that NHS Buckinghamshire patients are able to access high quality
equitable services across the whole county. There have also been issues accessing
training to support LARC provision in General Practice.
Brook
Brook (young people’s sexual health charity) currently provides a weekly clinic on a
Monday afternoon in Buckingham for those under 25 who wish to seek advice about
all aspects of sexual health. They are able to provide condoms, emergency hormonal
contraception and oral contraception for this group; with the only LARC method they
are able to provide being contraceptive hormonal injections. This service is only
18
Previously known as Family Planning Service
20
available in the north of the county so does not promote equitable access across
Buckinghamshire.
With a higher number of teenage conceptions leading to a termination rate in
Buckinghamshire and the very slow fall in teenage rates, it suggests that young
people are not accessing effective contraception and may be engaging in more risky
behaviour.
In 2010 an outreach clinic was opened in Burnham to begin to address this issue.
Access to Contraception Programme
The DH has provided £26.8 million nationally over three years for local health
services to ensure contraception is available in the right places at the right time. This
included a focus on access to LARC methods (Long-Acting Reversible
Contraception19), as NICE highlighted that if 7% of women switched from the
contraceptive pill to LARC methods, the NHS could save around £100 million through
reducing unintended pregnancies by 73,000 per annum.
Key Service Issues & Priorities:
Contraceptive Services








There is a need to address access to contraception to ensure equity
across the county and support patient choice.
Services need to be reviewed to consider the need to address a
patient’s sexual health and contraception needs holistically,
including building links between services and looking to develop
integrated services where possible.
A programme of work to increase access to contraception in line
with the DH programme needs to be developed and implemented.
A pilot has been commissioned to provide contraception with the
sexual health clinics in outreach settings. This will need to be
reviewed and if successful additional resources made available to
sustain this work.
There is a need to engage with patients and the public to
understand their needs and why there appears to be poor
engagement in contraceptive services as demonstrated by the high
termination rates.
The CASH service needs to be redesigned to enable it to focus on
providing a specialist level 3 contraception service.
Local training programmes (especially around LARC) need to be
established through the level 3 CASH provider to enable quality
contraceptive and sexual health services to be provided through
primary care (General Practice and Community Services).
Need to look into young people’s outreach services to increase
engagement of young people in sexual health and enable access to
contraception.
19
particularly the Intra-Uterine Device (the coil), the Intra-Uterine System (the Mirena coil) and
sub-dermal implants as long-acting contraceptive injections (Depo-Provera) are also LARC
methods, but these are not included in the government drive to increase LARC uptake as their
success depends on the patient attend 3 monthly for another injection, and so is more liable to
failure through non-effective use.
21
Community Pharmacies
Emergency Contraception Scheme
Community Pharmacies within Buckinghamshire play a key part in promoting access
to contraception for young people within Buckinghamshire. Currently 38 community
pharmacies throughout Buckinghamshire participate in NHS Buckinghamshire’s
Emergency Hormonal Contraception Scheme (EHC). This is a locally enhanced
service which provides free EHC to young women aged under 19 years in the county.
The service aims to make EHC more accessible to young women and contributes
towards reducing Buckinghamshire’s teenage conception rate and increasing
referrals to contraceptive services.
Other possibilities
There is potential to expand the Chlamydia Screening Programme to be offered at
community pharmacies, especially whenever a patient accesses EHC, and this needs
to be further investigated.
Community pharmacies offer anonymous open access, which can be valuable in
accessing young people and other vulnerable groups. Options to enhance the role of
community pharmacies in sexual health promotion should be further explored via the
new Healthy Living Pharmacy initiative.
In July 2011 Chlamydia screening for all 15 – 24 year olds is being rolled out to
pharmacies signed up to the EHC scheme. Testing and treatment is also available in
three central pharmacies in High Wycombe, Aylesbury and Chesham from October
2010. This increases the choice in sites for treatment for young people and is based
on their views captured during a series of focus groups in 2009.
Key Service Issues & Priorities:
Community Pharmacies





Uptake of the EHC scheme should be monitored to identify areas of
high usage for intervention. The scheme should also be promoted
within the wider context of sexual health to ensure that young people
are aware of its availability, but do not become reliant on the scheme
as a method of contraception.
Need to ensure that the issue of repeat users of the EHC scheme are
encouraged to link in with sexual health services to promote safer
behaviour and contraception.
Further investigation is needed into the role of community pharmacies
in the Chlamydia Screening Programme. There are opportunities to
link CSP with the EHC scheme, as well as opportunities for
opportunistic screening, treatment and promotion of the programme.
Need to ensure that Community Pharmacies signpost patients of all
ages to sexual health services to promote safe sex and access
screening as appropriate.
The role of community pharmacies in the promotion of the whole
sexual health agenda should be reviewed and enhanced where
possible.
22
Chlamydia Screening Programme
The Chlamydia Screening Programme was introduced by the DH in 2003 in an
attempt to reduce the dramatic rise in chlamydia in young people nationally, providing
free testing and treatment if needed to all under 25. It has been commissioned in
Buckinghamshire since 2007.
The Chlamydia Screening Office (CSO) in Buckinghamshire is provided by
Buckinghamshire Healthcare NHS Trust. The CSO provides:

Training and support to sites participating in the Chlamydia Screening
Programme
Coordination and management of test results
Treatment for those testing positive
Partner notification
Promotion and marketing of the programme through a range of media,
including their own local website (http://morethanahug.com/).




Chlamydia Screening is available through a number of sites, including non statutory
services and postal kits via the website.
Since 2007 there has been a year on year increase from the national target to screen
15% of the target population, to 35% in 2010-11, which NHS Buckinghamshire is yet
to be able to achieve. In 2012/13 there will be national changes to the chlamydia
indicator.
The uptake of chlamydia screening through core services (general practice,
community pharmacy, contraception, termination) has been poor across primary care.
NHS Buckinghamshire is currently looking at a number of options to pilot in 2010-11
to establish their success at integrating chlamydia screening into general practice.
National reports also question the value for money currently being achieved by this
programme, which needs to be addressed at all levels (nationally as well as locally).
Key Service Issues & Priorities:
Chlamydia Screening Programme (CSP)






There is a need to review current CSP and work with all providers to
look at ways to increase uptake of the screening programme to meet
the national targets
Focus on building chlamydia screening into core services in line with
national strategic direction, including implementing and reviewing a
number of pilots around various areas of primary care, including
general practice and community pharmacy
Review the resources dedicated to CSP in light of the national target
and local progress towards this
Review current CSP initiatives to establish their success and decide
whether to re-launch or decommission these initiatives
Ensure good links with external partners/organisations, such as
schools and colleges, to maximise on opportunities for chlamydia
screening
Investigate options for the provision of a sexual health GP clinical
champion to support engagement in sexual health programmes
including CSP.
23
HIV Services
Health
Outpatient care for people with HIV is provided by Buckinghamshire Healthcare NHS
Trust at the SHAW and Brookside clinics. Patients are also able to access HIV
outpatient care from out of area clinics, dependent on patient choice, an option taken
up by a number of patients.
Patients requiring in-patient care for illnesses secondary to their HIV, including those
needing a blood transfusion, are provided for at High Wycombe General Hospital,
although complex in-patient care is provided by the Infectious Diseases Unit in
Oxford.
Social Care
Buckinghamshire County Council (BCC) provides HIV support via one full-time senior
specialist social worker, who is currently supported by a part-time support worker.
This is funded via the ASG (AIDS Support Grant), which is made to councils from the
Department of Health as a contribution to the costs of social care for people living
with HIV in each area.
Voluntary Sector
The ASG is also used to commission voluntary sector support provision for people
affected and living with HIV. This is provided by The Crescent Support Group and
TVPS (Thames Valley Positive Support). Following the removal of the ring-fencing of
the ASG in 2010, BCC reviewed the funding made available to support people living
with HIV and the contract with TVPS and the part-time support worker were ceased.
Voluntary sector support provides:







An outreach worker who links with the local GUM services
Training for local social care services
A drop-in centre in Aylesbury & High Wycombe
Some outreach work to engage with high risk communities
Support with social needs, such as housing, employment, immigration &
benefits
Peer support
Health and wellbeing promotion.
HPA Data from 2007 shows Buckinghamshire to have a prevalence rate of 0.8320, the
3rd lowest prevalence across South Central SHA. However, in 2007 46% of those
newly diagnosed with HIV, were diagnosed late21. This was the second highest rate of
late diagnosis across the SHA, and is well above the national average (31%). This
suggests that stronger outreach programmes are needed to engage with relevant
populations about their risk and how HIV can be managed, to encourage more people
to come forward for testing. The use of technological developments, such as rapid
testing, also needs to be considered to address the high rates of late diagnosis.
HIV prevalence per 1,000 population aged 15 – 59 by local authority
Late diagnosis is classed as having a CD4 cell count less than 200 cells per mm3 within 30
days of diagnosis, and is well beneath the CD4 cell count where medication should be initiated
to prevent development of the disease and associated co-morbidities.
20
21
24
Key Service Issues & Priorities:
HIV Services

There is a need to understand why local HIV services may not be the
services of choice when people choose to access services out of area,
to enable local providers to develop services to meet local needs

Following the removal of the ring-fence for the ASG and the planned
changes to the health service, BCC and NHS Buckinghamshire need
to work together to review current provision and plan a coordinated
way forward to support people living with HIV

The high late diagnosis rate in Buckinghamshire suggests the need for
more pro-active engagement with high risk groups, as well as more
awareness of the risks of acquiring HIV and the need for testing

There is a need for a multi-agency review to ensure that the services
available to support people living with HIV continue to meet their needs
and are complimentary to each other, including supporting people’s
primary care needs

An HIV needs assessment and county wide review of all services that
provide all levels of support and care to people living with HIV is
recommended to support appropriate review of resource and
investment. This review would also ensure that local services meet
nationally recommended standards and are able to cope with the
increasing number of people living with HIV in the county

Clear referral pathways between all services need to be established
and communicated

Access to psychological support for children and adults affected and
infected with HIV needs to be reviewed to ensure appropriate support
is available

Investment in resources and services will need to keep pace with
the increasing numbers of HIV-infected persons requiring care,
especially as people live longer with the illness.
25
Termination of Pregnancy Services
Termination of pregnancy (ToP) services for unwanted pregnancies are provided by
bpas (British Pregnancy Advisory Service)22 for all patients except those with
significant co-morbidities23, and since 2010 have been commissioned in conjunction
with NHS Milton Keynes and NHS Oxfordshire following a competitive tender process
to ensure value for money is being achieved from the contract24. As part of this
retender, Early Medical Services (EMA) have been developed within each PCT to
increase local access to services to support patients to access ToP services under 10
weeks’ gestation.
bpas offer a range of services from a number of venues across the country. Locally
the following services are available:








Consultation and Counselling is available in Aylesbury, High Wycombe, Milton
Keynes and Oxford (from late 2010)
Telephone Counselling is also available (from 2010)
Procedures are available in London, Luton, Leamington Spa, and from 2010
High Wycombe, and Milton Keynes, with services being developed in Oxford –
venue is dependent on the procedure being undertaken and patient choice
24 hour support and booking line
Self referral is available
Provision of contraception post procedure, including LARC methods
Sign-posting to other services if patients decided to continue with the
pregnancy
Chlamydia Screening as part of the national programme.
Key Service Issues & Priorities:
Termination Services





The termination of pregnancy service needs to be retendered during
09/10 to ensure that the desired quality, access to local services and
value for money is achieved
NHS Buckinghamshire will work with regional NHS providers of ToP
services to ensure smooth pathways and patient choice are embedded
and patients with complex co-morbidities are able to access ToP
services rapidly where required
Maximise the uptake of contraception post termination procedure to
reduce the rate of repeat procedures
The quality of all terminations needs to be closely monitored to ensure
that services meet the needs of local patients, who may be reluctant to
verbalise issues with the service due to the sensitive nature of it
Ensure the uptake of chlamydia screening by people attending for
terminations is maximised.
22
Termination of pregnancy services for medical reasons are completed at the local acute
hospitals through the Obstetrics and Gynaecology services.
23 For patients with significant co-morbidities arrangements are in place with a number of NHS
providers dependent on the patient’s needs, gestation and patient choice. bpas have a
dedicated team to refer on these patients rapidly where required.
24 Termination of pregnancy services were previously jointly commissioned from bpas by NHS
Milton Keynes and NHS Buckinghamshire for a number of years.
26
Vasectomy and Sterilisation
Vasectomy services within Buckinghamshire are provided by two GP practices that
have historically provided the service based on an enhanced service to their GMS
contract. There is limited choice for patients, and there is often a long wait for a
procedure (currently 4-6 months). There is a mix of approaches used across services,
with the scapel-less technique the current best practice.
Access to vasectomy services is via GP referral after full consideration of all other
contraceptive methods and considerations for the risks and implications for the
procedure.
Female sterilisations are provided via gynaecological departments at general
hospitals. These procedures are rare though, as with the availability and reliability of
LARC methods, an invasive non-reversible procedure is rarely felt to be necessary.
Reversal of both vasectomy and sterilisation are not funded on the NHS unless in
extremely exceptional circumstances.
Key Service Issues & Priorities:
Vasectomy and Sterilisation Services



Urgent work is needed to deal with the large waiting lists and ensuring
that vasectomy is the most appropriate contraceptive procedure given
the low success rates of reversal (which is not NHS funded)
Vasectomy services need to be reviewed to ensure that the services
provided meet best-practice standards around access and technique
NHS Buckinghamshire needs to continue to ensure that all clinicians
promote LARC methods over vasectomy and sterilisation methods,
ensure that it is clear to the patient the low success rate of reversing the
procedure and the lack of NHS funding available to undertake this.
27
Psychosexual Services and Erectile Dysfunction
Relate provide psychosexual counselling services across Buckinghamshire to which
patients can be referred or self-refer if they have identified that they would benefit
from this type of support. There has been some concern about the appropriateness of
some of the referrals received by the service, suggesting that there may need to be
education about the function of psychosexual counselling.
Relate charges people for each session they attend, based on their ability to pay.
NHS Buckinghamshire provides a grant to the service to support those who are less
able or not able to pay to ensure that they can still receive the service.
There are no specific erectile dysfunction clinics available within Buckinghamshire.
Currently patients requiring this service have to be referred out of area, although
access to these clinics is not always easy for out of area patients as these clinics are
often primary care based. A local GP has provided an erectile dysfunction clinic via
pharmaceutical funding, but due to changes in the pharmaceutical funding rules this
clinic has not been able to continue on a regular basis.
Anecdotal evidence from local GPs is that referrals for patients with erectile
dysfunction are made to urology due to a lack of a viable alternative, but the coding of
urology appointments does not allow for the amount of activity this accounts for to be
unpicked. Within secondary care there is dedicated erectile dysfunction support
(specialist nurses) within the urology oncology department, but access to this
resource is limited to patients within this speciality.
Key Service Issues & Priorities:
Psychosexual and Erectile Dysfunction Services



Need to review provision of psychosexual counselling to ensure that
local provision meets local needs
A clear referral criteria and patient pathway needs to be established to
ensure that all referrals to psychosexual and erectile dysfunction
services are appropriate and that patients can access the most
appropriate service for their needs
Need to look into options for the provision of erectile dysfunction clinics
in primary care reflecting national and local priorities and best practice.
28
Sexual Assault & Exploitation
Sexual assault and exploitation are often hidden crimes, the effects of which can be
devastating and have life-long health implications. Appropriate support enables the
impact to be minimised and prevent further harm to both the individual and society.
There is national work around sexual violence and exploitation, especially violence
against women and girls. In response to government recommendations,
Buckinghamshire County Council is undertaking work to co-ordinate the local
response to sexual violence, and is looking to establish a sexual violence forum.
Nationally, the government has the expectation that each police area will have at
least one Sexual Assault Referral Centre (SARC) and that all victims will have access
to an Independent Sexual Violence Advisor (ISVA) by 2010.
SARCs provide a ‘one stop’ location where complainants of rape or sexual
assault/abuse can receive:





Appropriate medical care
Emotional support and counselling
Referral for follow-up by other agencies (e.g. GUM or ToP services)
Support for historic as well as acute incidents
Collation of forensic evidence for use at a later stage should the complainant
not want to pursue criminal proceedings at the time.
Buckinghamshire County Council support work around sexual violence and
exploitation. A number of services are available locally to support people who have
experienced or been affected by sexual abuse or exploitation25, including:




Aylesbury & Wycombe Rape Crisis
Victim Support
Aylesbury & Wycombe Women’s Aid
R-U-Safe?
A Thames Valley wide SARC was opened in April 2011 with sites in Slough and
Bletchley.
Key Service Issues & Priorities:
Sexual Abuse and Exploitation
 NHS Buckinghamshire will need to work with the Thames Valley wide
project to implement a SARC locally, including ensuring that the
necessary resources are available to support this.
 Clear links into and out of the SARC service must be in place once the
SARC service is operational.
 There is a lack of support services available for male victims of sexual
violence, therefore services should be looked to be developed to
account for this.
Clear care pathways and protocols must be established to support these
patients who present reporting sexual violence, including the use of early
evidence kits where appropriate.
25
There are also a number of national organisations that people can access including Stop it
Now!, Lucy Faithfull Foundation, NSPCC, Survivors UK and Mankind UK.
29
Sexual Health Promotion
Sexual Health Promotion is fundamental to achieving good sexual health for all
people within Buckinghamshire. Through awareness of all the issues associated with
sexual health and knowledge of where to access relevant services, the population of
Buckinghamshire will be able to enjoy relationships that are safe, healthy, and
consensual and free from discrimination, illness and disease.
The Sexual Health Network have an annual communication plan to link in with
national and coordinated local campaigns around specific aspects of sexual health.
There are specific schemes to promote sexual health, run and delivered through
various collaborations:

C-Card – This scheme provides access to free condoms (and lubrication) from
a range of non statutory settings, and is mainly26 aimed at young people under
the age of 25. Sites are trained in demonstrating best practice use of condoms
and how to discuss issues around sex and relationships with young people.
The scheme is coordinated by Brookside Contraceptive and Sexual Health
(CaSH) clinic, who also provide some of the Sex Matters training required to
become a C-Card site. The scheme has been in place since November 2008
and currently has over 25 sites signed up to the scheme. It is intended that the
number of sites will continue to increase and the opportunity to link with the
CSP will be maximised.

Sexual Health Bucks Website – During 2009 NHS Buckinghamshire
launched the Sexual Health Bucks website to promote all local services and
information around sexual health (www.sexualhealthbucks.nhs.uk). The
website was developed from the Sexual Health Marketing sub-group of the
Sexual Health Network, and will be reviewed and updated in 2011.

Sex Matters Training – Sex Matters training is commissioned to support all
professionals working with young people to be able to talk about sex and
relationships, including sign-posting them to appropriate services for further
advice or treatment, if needed, and at the higher level demonstrating and
advising on condom use and pregnancy testing.

Healthy Schools – Healthy Schools was a government initiative to promote a
whole child/whole school approach to health, to reduce health inequalities,
improve health and social inclusion and raise pupil achievement. Whilst this
programme has been discontinued, the Sexual Health Network continue to
link in with the schools service at BCC to support the health and wellbeing
agenda, including the Health Zone programme commissioned by BCC.

Healthy FE – Healthy FE (Further Education) is an extension of the principles
of the Healthy Schools programme for the further education setting. This
programme is a newer programme and therefore has only recently been
initiated. Again, NHS Buckinghamshire and the local providers of sexual
health services are working closely with partners in education and the local
authority to support its implementation.
26
The C-Card scheme is also used to provide free condoms to those living with HIV via the
voluntary sector services to help prevent onward transmission of the virus.
30
Key Service Issues & Priorities:
Sexual Health Promotion




C-Card scheme: there needs to be an increase in the number of sites
registered with the scheme, and wider promotion of the scheme should
be undertaken to ensure that it is being optimally used. Clear links with
CSP should also be maximised.
The website review needs to build on initial engagement with patients
and the public to ensure that it remains a valuable local resource.
Healthy Schools/FE: The Sexual Health Network will continue to look
to support this work and increase the awareness and education around
sexual health delivered via these avenues. Providers will be
encouraged to link with this programme to help ensure the standards
of sexual health education that is delivered.
Outreach: There is a gap in targeted outreach to high risk groups.
Work should be undertaken to identify resources to support this and
the best model to achieve this across Buckinghamshire.
31
Patient and Public Engagement
Patient and Public Engagement is key to developing services that fully meet the
needs of the local population. This is especially so with sexual health services, where
poorly designed services that do not meet local people’s needs can lead to poor
engagement with services and then potentially to sexual ill health or unintended
conception.
Patient and Public Engagement work to date includes:





Collection of patient feedback by all service providers, which is used to
develop services to meet patient needs
Focus groups held by the Public Health department within NHS
Buckinghamshire to look at engagement in chlamydia screening
Engagement with young people around the accessibility and usefulness of the
sexual health website and incorporation of ideas for improvement into the final
version
Completion of a piece of work by a specialist registrar within the C&SH service
looking at making sexual health services more young people friendly within
Bucks, and the implementation of You’re Welcome standards
Dedication of Sexual Health Network meeting to review how patient feedback
is collected and used across the local sexual health economy, including guest
speaker from Brook on how they engaged young men in local services.
Since 2010 this work has developed further including:




Public Consultation via patient groups, the LINk and Overview and Scrutiny
Committee at BCC on the draft Sexual Health Strategy
A piece of consultative work commissioned by Public Health to understand the
views of local women on contraception
Snapshot views of young people’s understanding of chlamydia captured via a
local radio broadcast and vox pox with students in a Further Education setting
Online anonymous engagement with the public to understand local views is
currently being developed.
The Sexual Health Network will continue to monitor the progress of patient and public
engagement in sexual health services, and work to come up with innovative ways to
engage with people from all backgrounds to ensure fair representation is made.
32
Sexual Health Strategic Aims and Priorities
Local Health Inequalities
The Sexual Health Needs Assessment and Sexual Health Population Profile update
for 2011 continue to highlight the main groups who experience sexual health
inequalities and are at high risk of sexual ill health:




Young people, especially those in areas of deprivation within
Buckinghamshire
Lesbian, Gay, Bisexual and transgender (LGBT) community, especially men
who have sex with men
Commercial sex workers
Minority ethnic groups.
Other identified groups that are also more likely to experience sexual health
inequalities include:






Homeless people
People with learning, physical and sensory disabilities
Offenders
People with drug and alcohol abuse issues
People living with HIV
Asylum seekers and recent migrants.
Strategic Aims
In order to ensure that NHS Buckinghamshire provides the best possible services for
the local population the following issues need to be addressed:





The current service provision across the county is not equitable and there are
differences in the availability of access to services
Reducing late diagnosis and undiagnosed sexually transmitted infections
including HIV
Improving access to contraceptive services to reduce unintended pregnancies
Reduce the number of teenage conceptions leading to an abortion, as these
are higher than the national average and suggest that both contraception and
risky sexual behaviour needs to be addressed
NHS Buckinghamshire needs to work with all providers to understand and
address barriers preventing achievement of national and regional targets.
It is widely acknowledged that whilst much work has been undertaken to improve the
sexual health of the local population, mainly in recent years, much more is needed to
really coordinate services and address the inequalities that exist within the county.
All stakeholders are committed to continuing to work with NHS Buckinghamshire to
develop services to meet the needs of the local population and achieve world class
sexual health services for the people of Buckinghamshire.
33
Priorities
Priorities for each year covered in this strategy, and the progress against these to
date are outlined below.
Year 1 Priorities (2009/10):

A new sexual health strategy and comprehensive sexual health needs
assessment has been produced, following engagement with all local
stakeholders, to provide a strategic view and direction of travel for the
development of local sexual health services and sexual health promotion
across Buckinghamshire.

GUM access has improved, with national targets for 48-hour access being
achieved and maintained.

Sexual Health Network redeveloped with refreshed membership, terms of
reference and coordinated delivery plans across local stakeholders.

Local termination of pregnancy services reviewed and retendered to achieve
maximum value for money and enhance local provision, especially around
contraception post procedure.

Supported implementation of the Healthy Schools programme, with sexual
health being a core part of this programme.

Sexual health website launched, and marketing and communication plans
developed support sexual health promotion, with appropriate new resource
materials produced and disseminated.

Focus groups held with young people to inform the commissioning of the local
chlamydia screening programme

Vasectomy services reviewed to address waiting list issues and ensure best
practice techniques being used.

Workforce reviewed in specialist services to resolve service delivery issues.
Year 2 Priorities (2010/11):

Updated the sexual health profile

Issued a service specification for a new level two integrated sexual health
service

Integration and development of GUM services with service specifications
reviewed and implemented across both clinics to standardise services.

Review of HIV services provided under the ASG to ensure minimal reduction
of service provision post ring-fence removal.

Local provision of termination services developed and operational.
34

Thames Valley wide SARC commissioned and operational with sites in Slough
and Bletchley.

Specialist contraception service reviewed and agreement from the Overview
and Scrutiny Committee to concentrate resources at Aylesbury and High
Wycombe hubs.

Training programmes developed and delivered to support primary care delivery
of sexual health services, including specialist LARC training programmes.

Programme of pilots and training in place to support DH Access to
Contraception programme, including:
- Outreach pilot including contraception as part of the level 2 clinics
- Further Education and Higher Education mobile clinics extended to
include contraception on a pilot basis
- Brook service piloted in Burnham
- Local GPs funded to train/re-train in LARC fitting.

Audit of women’s views on contraception commissioned and delivered,
capturing the views with nearly 800 women across a wide range of
Buckinghamshire residents via online surveys, user questionnaire and focus
groups.

New clinical lead in place to develop contraception services and training across
Buckinghamshire.

Work programme developed to embed chlamydia screening into core services
including:
- Increasing uptake of CSP in contraception services
- Developing CSP as part of the C-Card scheme
- Employing a GP clinical champion to support the implementation of CSP
in general practice
- Developing local EHC schemes in community pharmacy to include CSP
- Developing test and treatment pilots for CSP in 3 community
pharmacies.
- Taking part in a SHA wide social marketing project to increase
Chlamydia screening with the over 21 age group

Christmas campaign delivered via sixth forms, Further Education and Higher
Education, youth and community settings and via public transport on safer sex
and advertising the local website and postal test kits for Chlamydia.
Year 3 (2011/12):

All remaining services will be reviewed in light of the sexual health needs
assessment and local strategy, and then re-designed/ re-commissioned to
meets the demand and needs of the local population and/ or identify
incongruence’s between capacity and demand.

Development of High Wycombe specialist contraception hub with concentration
of resources on High Wycombe and Aylesbury, and communication plans once
detailed operation plans in place.
35

Review local access to erectile dysfunction services.

Review access of young men to services across Buckinghamshire.

Review and refresh sexual health website.

Develop a joint strategic plan for HIV between NHS Buckinghamshire and
Buckinghamshire County Council to ensure that future plans and service
developments around HIV service provision are complimentary and best value
for money is achieved.
Year 4 onwards (2012 onwards):

NHS Buckinghamshire will work in conjunction with Bucks County Council to
develop appropriate action plans on sexual health in particular, targeting young
people in line with the NHS changes and transfer of public health over to local
authority

Develop outreach services to engage high-risk groups.

Review implications of health service structural changes to ensure sexual health
services are not negatively impacted on by any changes and any opportunities
to build on partnership working are identified.

Look at feasibility of introducing a centralised booking service for all sexual
health services to enable patients to easily access the most appropriate service
for their needs.

Expand engagement work to ensure that services truly reflect the local
population, not just those who are most articulate.

On-going review and development of services in line with national policy
developments and available resources.

Evaluate impact of projects undertaken in years 1 – 3 to establish success in
improving the sexual health of the local population and to ensure the strategy
remains fit for purpose.

Ensuring all services have progressed to meet the national You’re Welcome
standards to provide services that meet the needs of young people.
To support all of the above priorities, NHS Buckinghamshire will look at the following:






Workforce development issues
Access
Patient pathways
Strategy and engagement work
Developing robust contracts and performance monitoring with all providers
Promoting partnership working across the local sexual health economy
36
NHS Buckinghamshire and the
local Sexual Health Network will continue the
progress made towards the achievement of
good sexual health for
all residents of Buckinghamshire.
37
References & Bibliography
There have been a number of strategies and supporting guidance around many
aspects of sexual health in recent years. These all shape the development of sexual
health services nationally and locally. Appendix 3 lists a number of the wide variety of
guidance and reports available to support the development of sexual health and HIV
services.
The key documents used in this strategy are:
-
-
-
The National Strategy for Sexual Health and HIV, DH, 2001
The National Strategy for Sexual Health and HIV. Implementation action plan,
DH, 2002
Effective Commissioning of Sexual Health and HIV Services. A Sexual Health
and HIV Commissioning Toolkit for Primary Care Trusts and Local Authorities,
DH, 2003
Standards for the management of sexually transmitted infections (STIs),
MedFASH & BASHH, 2010
Progress and priorities – working together for high quality sexual health.
Review of the National Strategy for Sexual Health and HIV, MedFASH, 2008
Moving forward: Progress and priorities – working together for high-quality
sexual health. Government response to the Independent Advisory Group’s
review of the National Strategy for Sexual Health and HIV, DH, 2009
Sexual health – worth thinking about. A paper to inform national strategic
planning for sexual health and HIV in 2011 and beyond, MedFASH, 2010
The Time is Now Achieving World Class Contraceptive and Abortion Services,
Independent Advisory Group on Sexual Health and HIV, 2009
Clinical Guideline 30:Long Acting Reversible Contraception, NICE, 2005
The Time is Now Achieving World Class Contraceptive and Abortion Services,
Independent Advisory Group on Sexual Health and HIV, 2009
Long Acting Reversible Contraception- Clinical Guideline, NICE, 2005
Framework for Better Living with HIV in England, Sigma Research, 2009
Recommended Standards for NHS HIV services, MedFASH, 2003
Standards for HIV Clinical Care, BHIVA, 2007
Buckinghamshire Joint Strategic Needs Assessment,
http://www.buckinghamshire.nhs.uk/?page_id=667
Sexual Health in Buckinghamshire - a review, Supporting Public Health and NHS
Buckinghamshire, 2009.
Sexual Violence and Abuse Report for Buckinghamshire, 2009, Buckinghamshire
County Council.
Alcohol Harm Reductions Strategy, 2004, Prime Minister’s Strategy Unit
Teenage Pregnancy Strategy 2009-11, Buckinghamshire County Council
38
Appendices
Appendix 1: Terms of Reference for the Sexual Health Network

Developing a strategic, collaborative and co-ordinated approach to the
implementation of national sexual health and related strategies and
programmes working across key sexual health provider services, county
and district councils, NHS Trusts and the community and voluntary
sector.

Identifying local priorities across Buckinghamshire.

Ensuring resources are targeted to those most at risk of poor sexual
health.

Developing a Buckinghamshire Sexual Health Strategy with associated
delivery plans.

Providing advice and a co-ordinated approach by working jointly with
health commissioners.

Acting as a key reference point to any local clinical networks and in an
advisory capacity for implementation of NICE guidance and MEDFASH
standards.

Support the development of early intervention and health promotion
opportunities within services.

Act as the umbrella group for a number of task orientated subgroups
(named below) and ad hoc core working groups as necessary.
- Communications and Marketing Working Group - led by Public
Health, NHS Buckinghamshire
- Further Education Programme Working Group - led by Public
Health, NHS Buckinghamshire
- Local Chlamydia Steering Group - led by CASH Service,
Buckinghamshire Healthcare NHS Trust

To work in close liaison with the Buckinghamshire County Council HIV
Steering Group and Teenage Pregnancy Reference Group.
39
Appendix 2: Levels of Sexual Health Service Provision
The following lists comprise elements of STI management that are appropriate at
various levels of service provision, as defined in the National Strategy for Sexual
Health and HIV, (DH, 2001).
There should be clear links between services providing the different levels of service,
with services at each level providing the services outlined at the lower levels in
addition to the level specific services.
Level 1

Sexual history-taking and risk assessment
- Including assessment of need for emergency contraception and HIV
post-exposure prophylaxis following sexual exposure (PEPSE)

Signposting to appropriate sexual health services

Chlamydia screening
- Opportunistic screening for genital chlamydia in asymptomatic males
and females under the age of 25

STI screening for women and heterosexual men dependent on clinical
presentation

HIV testing
- Including appropriate pre-test discussion and giving results

Point of care HIV testing
- Rapid result HIV testing using a validated test (with confirmation of
positive results or referral for confirmation)

Screening and vaccination for hepatitis B
- Appropriate screening and vaccination for hepatitis B in at-risk groups

Sexual health promotion
- Provision of verbal and written sexual health promotion information

Condom distribution

Psychosexual problems
- Assessment and referral for psychosexual problems
Level 2
Incorporates Level 1 plus:

STI testing and treatment of symptomatic but uncomplicated infections
in men (except MSM)* and women excluding:
-
Men with dysuria and/or genital discharge**
Symptoms at extra-genital sites, eg rectal or pharyngeal
Pregnant women
Genital ulceration other than uncomplicated genital herpes
40
Level 3
Incorporates Levels 1 and 2 plus:

STI testing and treatment of MSM*

STI testing and treatment of men with dysuria and genital discharge**

Testing and treatment of STIs at extra-genital sites

STIs with complications, with or without symptoms

STIs in pregnant women

Recurrent conditions
- Recurrent or recalcitrant STIs and related conditions

Management of syphilis and blood borne viruses
- Including the management of syphilis at all stages of infection

Tropical STIs

Specialist HIV treatment and care

Provision and follow up of HIV post exposure prophylaxis (PEP)*** both
sexual and occupational

STI service co-ordination across a network including:
- Clinical leadership of STI management
- Co-ordination of clinical governance
- Co-ordination of STI training
- Co-ordination of partner notification
* The testing and management of men who have sex with men (MSM) has been
defined as an element of care at Level 3 as the majority of infections in this group are
in the rectum and/or pharynx rather than the urethra, with rapid access to
microbiology being needed to undertake these tests.
** The appropriate management of men with dysuria and/or urethral discharge
requires immediate microscopy, usually only available at specialist GUM (Level 3)
services so the testing and treatment of such men has been defined as an element of
care at Level 3.
*** PEP ‘starter packs’ are often available in other settings such as Accident and
Emergency or Occupational Health, but referral to a specialist GUM (Level 3) service
is required for ongoing management and provision of antiretroviral drugs.
41
Appendix 3: Sexual Health Guidance Documents
National Guidance for Sexual Health Services
Commissioning:






Choosing Health: Making healthy choices easier, DH, 2004
NHS Next Stage Review, DH, 2008
NHS Operating Framework, DH (refreshed annually)
World Class Commissioning, DH
Wanless Reports
Our health, our care, our say: a new direction for community services, DH, 2006
These all provide frameworks that enable the prioritisation of sexual health at a local
level. Within all these policy mechanisms, the focus is on quality of service, high
standards in commissioning and good local decision-making to produce services that
meet local need. These documents also promote keeping people healthy instead of
just treating illness
Sexual Health Commissioning Specific:







Effective Commissioning of Sexual Health and HIV Services. A Sexual Health
and HIV Commissioning Toolkit for Primary Care Trusts and Local Authorities,
DH, 2003
Five steps to better sexual health & supporting people with HIV, THT, 2008
The NHS Trusts and PCTs (Sexually Transmitted Diseases) Directions, 2000
Recommended standards for sexual health services, MedFASH, 2005
Integrating the National Strategy for Sexual Health and HIV with Primary
Medical Care Contracting, DH, 2005
Health Economics of Sexual Health: A Guide for Commissioning and
Planning, DH, 2005
The Economics of Sexual Health, 2005, FPA
National Sexual Health Strategy:





Progress and priorities – working together for high quality sexual health.
Review of the National Strategy for Sexual Health and HIV, MedFASH, 2008
Moving forward: Progress and priorities – working together for high-quality
sexual health. Government response to the Independent Advisory Group’s
review of the National Strategy for Sexual Health and HIV, DH, 2009
Sexual health – worth thinking about. A paper to inform national strategic
planning for sexual health and HIV in 2011 and beyond, MedFASH, 2010
The national strategy for sexual health and HIV, DH, 2001
The national strategy for sexual health and HIV. Implementation action plan,
DH, 2002
42
HIV:













Recommended Standards for NHS HIV services, MedFASH, 2003
Standards for HIV Clinical Care, BHIVA, 2007
The African HIV Prevention Handbook, NAHIP, 2009
The Knowledge, The Will and The Power: Planning Prevention Framework,
NAHIP, 2008
HIV and AIDS in African Communities: A Framework for Better Prevention and
Care, DH/NAT/AHPN, 2005
‘Don’t Forget the Children’. Guidance for the HIV testing of children with HIVpositive parents, BHIVA/ BASHH/ CHIVA, 2009
Children in need and blood borne viruses: HIV and hepatitis, DH, 2004
HIV Testing in Termination of Pregnancy Services: Conference Paper, BHIVA,
2009
Framework for Better Living with HIV in England, Sigma Research, 2009
Building on progress. Enhancing the response to HIV in England, Independent
Advisory Group on Sexual Health and HIV, 2009
HIV in the United Kingdom: 2008 Report, HPA, 2008
Commissioning HIV Prevention Activities in England, NAT, 2007
The AIDS Support Grant: Making a difference?, NAT, 2009
Contraception:


The Time is Now Achieving World Class Contraceptive and Abortion Services,
Independent Advisory Group on Sexual Health and HIV, 2009
Long Acting Reversible Contraception- Clinical Guideline, NICE, 2005
STI:


Genitourinary Medicine 48-hour Access: Getting to target and staying there,
DH, 2008
Standards for the management of sexually transmitted infections (STIs),
MedFASH & BASHH, 2010
Termination of Pregnancy:


Standard Service Specification Template, DH, 2009
The Time is Now Achieving World Class Contraceptive and Abortion Services,
Independent Advisory Group on Sexual Health and HIV, 2009
Teenage Pregnancy:



National Teenage Pregnancy Strategy, Department of Health and Department
for Children, Schools and Families, 1999
Teenage Pregnancy Strategy: beyond 2010, Department for Health and
Department for Children, Schools and Families, 2010.
Teenage Pregnancy and Sexual Health Marketing Strategy, Department of
Health and Department for Children, Schools and Families, 2009.
43
Workforce:




Primary Care Service Framework: Management of Sexual Health in Primary
Care, NHS Primary Care Contracting, 2007
Sexual health competences: an integrated career and competence framework
for sexual and reproductive health nursing across the UK, RCN, Revised 2009
Quality Standards for sexual health training: Striving for excellence in sexual
health training, DH, 2005
The Manual for Sexual Health Advisers, Society of Sexual Health Advisers
(SSHA), 2004
HPA:





Sexually Transmitted Infections and Young People in the United Kingdom:
2008 Report
Sexually Transmitted Infections and Men who have Sex with Men in the UK:
2008 Report
Sexually Transmitted Infections in Black African and Black Caribbean
Communities in the UK: 2008 report
New guidelines for HIV testing and areas where wider HIV testing policies
should be considered, HPA, 2008
HIV in the United Kingdom: 2008 report
Other:






Under 16s: consent and confidentiality in sexual health services, FPA, 2009
Evaluation of One-Stop Shop Models of Sexual Health Provision, UCL, 2007
One to one interventions to reduce the transmission of sexually transmitted
infections (STIs) including HIV, and to reduce the rate of under 18
conceptions, especially among vulnerable and at risk groups, NICE, 2007
You’re Welcome quality criteria. Making health services young people friendly,
DH, 2007
Independence, well-being and choice: our vision for the future of social care for
adults, DH, 2005
Local Government and Public Involvement in Health Act, 2007
44