Commissioning the Future Sexual Health Services in Enfield

2. Commissioning “The purpose of commissioning is to maximise the health of a population and minimise illness by purchasing health services and by influencing other organisations to create conditions which enhance people’s health.” Effective Commissioning of Sexual Health and HIV Services A Sexual Health and HIV Commissioning Toolkit for Primary Care Trusts and Local Authorities DH 2003

4. Spending on contraception DH baseline review of contraceptive services 2006 showed Enfield spends an average amount on contraceptive services ie around £11.67 per female aged 15 – 49. This includes GP, pharmacy and RASH prescribing. NB also includes RH level 3 services

5. Overview Does EPCT need its own specialist sexual health service? How much specialist sexual health care should EPCT provide and who should provide it? Drivers of change Future scenarios “Tell us what you want, what you really, really want…..”

6.  The policy environment Our health, our care, our say: a new direction for community servicesJanuary 2006

7. The policy environment Our health, our care, our say: a new direction for community servicesJanuary 2006

8. Does EPCT need its own specialist SH service? GUM health needs in Enfield cannot be met by primary care alone. All but 3 London PCTs commission local GUM units. Without a local specialist service EPCT will have to mission supervision for primary care elsewhere.

9. Does EPCT need its own specialist SH service? Some vulnerable groups – particularly teenagers – are less likely to access primary care Many clients want an “out of hours” service Primary care – at present – cannot provide the full range of level 2 &3 services Level 1 – 3 services are needed to provide training for primary care clinicians.

10. How much specialist care is enough?GUM Consultations per population in London boroughs

11. How much specialist GUM health care is enough ? Aim: 56 consultations/year per 1000 population = 15,800 consultations for EPCT residents/year Current provision: 12,500 of which about 7000 are provided by RASH at the Town Clinic

12. Could Primary Care provide > 50% of the GUM care in EPCT by 2010 ? Ambiguity in the primary care contract. No NSF. Limited capacity. Limited expertise. Only a small proportion of STIs are diagnosed in primary care.

14. How did we achieve this3 priorities: innovation, innovation, innovation Nurse start to finish care for most patient Clear standards of care Syndrome driven protocol “Nothing to declare” clinic What is next Nearly meeting the 48 hour target without significant extra resources Toolkit for primary care providers on intranet New service outlet in Edmonton New IT system pending

15. GUM care for EPCT residents

16. Why provide contraception? The cost benefit of contraception is well established and has been estimated at £11 for every £1 spent. It is estimated that the prevention of unplanned pregnancies by NHS contraceptive services already saves the NHS over £2.5 billion a year.  

17.  International Conference on Population and Development – Cairo 1994: “ ….. a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity, in all matter relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, affordable and acceptable means of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law …..”

18. Teenage pregnancy target Reduce the under 18 conception rate by 50% by 2010: Teenage Pregnancy Strategy 1999 ‘National Standards, Local Action’ planning framework 2005-08. NOTES FOR PRESENTERS The Teenage Pregnancy Strategy set the target of reducing conceptions in under 18s by 50% by 2010 from the 1998 baseline. Reference : Social Exclusion Unit (1999) Teenage Pregnancy. London: Dept for Education and Skills. (available from www.dfes.gov.uk/teenagepregnancy/dsp_content.cfm?pageID=87). The Sexual Health Strategy (2001) reiterated the target as part of a broader strategy to improve sexual health. Reference: Department of Health (2001) The national strategy for sexual health and HIV. London: Department of Health (available from www.dh.gov.uk). The Public Health White Paper ‘Choosing Health’ sets out comprehensive measures for improving sexual health and introduces sexual health into Local Delivery Plans (LDP) for the first time Reference: Department of Health (2004) Choosing health: making healthier choices easier. London: Department of Health (available from www.dh.gov.uk). The Health and Social Care Standards Planning Framework 2005/6 – 2007/8 refers to the national target. Reference: Department of Health (2004) National Standards, Local Action.  Health and Social Care Standards Planning Framework 2005/6 – 2007/8. London: Department of Health. The Department of Health will carry out an audit of PCTs’ contraceptive care services in early 2006. NOTES FOR PRESENTERS The Teenage Pregnancy Strategy set the target of reducing conceptions in under 18s by 50% by 2010 from the 1998 baseline. Reference : Social Exclusion Unit (1999) Teenage Pregnancy. London: Dept for Education and Skills. (available from www.dfes.gov.uk/teenagepregnancy/dsp_content.cfm?pageID=87). The Sexual Health Strategy (2001) reiterated the target as part of a broader strategy to improve sexual health. Reference: Department of Health (2001) The national strategy for sexual health and HIV. London: Department of Health (available from www.dh.gov.uk). The Public Health White Paper ‘Choosing Health’ sets out comprehensive measures for improving sexual health and introduces sexual health into Local Delivery Plans (LDP) for the first time Reference: Department of Health (2004) Choosing health: making healthier choices easier. London: Department of Health (available from www.dh.gov.uk). The Health and Social Care Standards Planning Framework 2005/6 – 2007/8 refers to the national target. Reference: Department of Health (2004) National Standards, Local Action.  Health and Social Care Standards Planning Framework 2005/6 – 2007/8. London: Department of Health. The Department of Health will carry out an audit of PCTs’ contraceptive care services in early 2006.

19. Teenage Pregnancy in Enfield

20. We now have two years to halve our teenage pregnancy rate in Enfield! Strong senior leadership and partnership working Good, accessible sexual health services for young people 4YP clinics and drop-ins School based and outreach services Targeting of the most vulnerable SRH education in and outside school Aspiration

21. FPA: The economics of Sexual Health Looked at pregnancies prevented if all women who wanted a LARC method were able to access it. “Using data from the LARC economic evaluation it is clear that over 500,000 unintended pregnancies can be prevented, thus producing a net saving of over £650 million over 15 years.”

22. LARC 8% of women in UK are using LARC compared with 14% in Europe. In Enfield: LARC = 4% of GP contraceptive prescribing, 8.7% RASH Main barrier to LARC nationally is lack of fitters and trainers

23. Cost of implementing NICE LARC guideline It is estimated that implementing the guidance in England will deliver an annual saving of £102.3 million. There will be an initial non-recurrent cost of £900K to train additional staff to fit intra-uterine devices and implants. NOTES FOR PRESENTERS The costing template is a spreadsheet template that allows local users to estimate the costs of implementation, taking into account local variation from the national estimates. This will highlight both significant new costs associated with implementation and any opportunities for disinvestment. The template can be obtained from the NICE website….link to www.nice.org.uk/implementation JENNIFER FIELDS TO PROVIDE TEXT NOTES FOR PRESENTERS The costing template is a spreadsheet template that allows local users to estimate the costs of implementation, taking into account local variation from the national estimates. This will highlight both significant new costs associated with implementation and any opportunities for disinvestment. The template can be obtained from the NICE website….link to www.nice.org.uk/implementation JENNIFER FIELDS TO PROVIDE TEXT

24. Why we should implement the LARC guideline Improve services by giving women more choice. Help reduce numbers of unintended pregnancies. More cost-effective use of NHS resources. NOTES FOR PRESENTERS Summary of the benefits of implementing the LARC guideline. You may wish to use it to encourage discussion about the specific benefits to your locality. Implementing this guideline will help you meet the target for halving the conception rate among under 18s by 2010. The term ‘cost-effective’ is used here to mean value for money. A specific healthcare treatment is said to be cost-effective if it gives a greater health gain than could be achieved by using the resources in other ways. NOTES FOR PRESENTERS Summary of the benefits of implementing the LARC guideline. You may wish to use it to encourage discussion about the specific benefits to your locality. Implementing this guideline will help you meet the target for halving the conception rate among under 18s by 2010. The term ‘cost-effective’ is used here to mean value for money. A specific healthcare treatment is said to be cost-effective if it gives a greater health gain than could be achieved by using the resources in other ways.

25. Does EPCT need its own specialist sexual health service? Yes, as the alternatives would be to commission consultant supervision from outside which may be difficult. Yes, as the alternatives would be to pay more PbR to other GUM units Yes until primary care can provide all levels of contraceptive care, to all groups, at all times Yes until primary care can provide training.

26. How much specialist sexual health care should EPCT provide and who should provide it? To reach the London median number of GUM consultations/population 20% more GUM consultations per year are required. Assuming that all GUM care should be provided locally an additional 8500 standard consultations/year are required. Currently half of all GUM consultations for EPCT residents occur outside of Enfield. The PbR cost of this will be about 0.8 million £ or 1.9 times the annual RASH GUM budget. At present although primary care provides over half of contraceptive provision, particularly pills, it does not contribute much to the provision of sexual health care (diagnosis of STIs) but this can and should change.

27. What does RASH do at present? Different clinics in different settings Integrated sexual health for teenagers Integrated sexual health for adults including nothing to declare Contraceptive clinics across the borough with some infection testing Specialist level 2 &3 LARC clinics

28. Consultant referral clinics FP and GUM - level 3 Gynaecology in the community- level 3 Psychosexual medicine - level 3 Termination of pregnancy in partnership with bpas - level 3 Cervical screening – limited at present

30. Drivers of change Change in policy and financial environment Change in technology Change in culture of service delivery Commissioning expectations (also influenced by demographic and epidemiological changes) Changes in consumer expectations patients primary care, tertiary care local government

31. Unacceptable scenarios “Quantity first” focus on uncomplicated patients uncomplicated patients have the same PbR as complex ones rapid turn over = good waiting times excellent statistics brownie points financially highly viable low returns on health

32. 2. “Quality first” (the traditional hospital approach) focus only on STI care within the clinic same PbR as a focus on “sexual and reproductive health” or “health”

33. Scenario 3The (future) RASH Approach “Sexual and reproductive health first” focus on sexual and reproductive health within the PCT develop level 1 and 2 care capacity within the PCT training clinics develop PCT wide quality assurance supervision of primary care service provision All clinics to provide level 1-2 ? 3 sexual and reproductive health for all service users independent of point of access focus on hard to reach and/or difficult to manage patients OK statistics good returns on health financially viable

34. Scenario 4The “Ideal World Approach” “Health first” as for RASH + Outreach to hard to reach patients young people, MSMs, CSWs, mental health patients, refugees, non-English speaking population Screening, initial management ± sign posting for common health problems Develop care pathways from RASH into primary care possibly adequate statistics excellent returns on health probably financially viable many referrals to primary care

35. How common are “other” health problems in sexual health service users?

36. What would EPCT get from sexual health in the future RASH scenario Level 1-2-3 sexual health care for SH service users. Structured world class training and support. distance learning and training clinic on line, e-mail and telephone support “Home visits” (if you wish one of our team will come to your surgery) Contact management you give us names and mobile numbers we do the rest

37. What would EPCT get from us in the “Ideal World” scenario As above + Health care (including outreach for hard to reach patients) drugs and alcohol ? sign posting to primary care or specialist services mental health assessment where clinically indicated ? sign posting to primary care or specialist services interpersonal violence assessment and advise ? sign posting, Social service referral if child protection issue, collaboration with primary care or specialist services initial assessment and management of sexual dysfunction ? sign posting to primary care or specialist services stop smoking advise ? sign posting to primary care

38. At your service You want an excellent SH and RH service training, support for primary care providers We employ a “future RASH model”. To do this we need: 2/3 of PbR (actually reaching our department - up from current 48%). Freedom to develop and collaboration with primary care, public health and commissioning Plus specifically commissioned training clinics more time available for senior staff to monitor and supervise

39. You want an excellent SH and RH service training, support for primary care providers health care for sexual health service users We employ an “Ideal World model”. We need 3/4 of PbR (actually reaching our department, up from current 48%). Freedom to develop and collaboration with primary care, public health and commissioning Plus specifically commissioned outreach clinics (teenagers, refugees, Turkish, homeless, MSM, mental health patients) training clinics more time available for senior staff to monitor and supervise

40. Sexual health care in Enfield is excellent value for money. RASH cannot reach GUM or TP targets alone. We will help in any way you want as long as it gets commissioned.

41. Why you should choose the (future) RASH or “Ideal World” Model In the UK people don’t die from STIs other than HIV. (200 deaths/year are caused by HIV). The main cause of death in the RASH service user age group are accidents, interpersonal violence and suicide. The main health problems in the RASH service users in Enfield are related to unplanned pregnancy risks, alcohol, drugs, inter-personal violence, and to a lesser degree to STIs and STI risks. The incidence of having or causing a pregnancy for heterosexual SH patients is higher than that of catching any STI. The Narrow Specialist Centre approach will not address these problems

43. Increasing capacity in primary care DFFP training - basic reproductive and sexual health Theory course – local or on line Practical training – in dedicated local training clinics? LARC training – in your practice if you wish

44. Action How do we develop partnership between Sexual health Services primary care and commissioners? Is there a need for a local Enfield Sexual Health Network – as part of North Central Sector Sexual Health Network? What are y/our educational needs? How should we finance service delivery and training?