Sexual & Reproductive health and HIV is a major public health issue. Good sexual health is an important aspect of health & well being and vital that people have the information, confidence and means to make choices that are right for them. Helps people to develop positive relationships and enables them to protect themselves & their partners from infections, disease and unintended pregnancy.Investment in sexual health services and preventing risk taking behaviour delivers healthcare and wider societal savings through preventing unplanned pregnancies and reducing transmission of STIs & HIVThose at highest risk of poor sexual health include young people, msm, african communities, sex workers, victims of sexual abuse and other vulnerable groups
Abortion rate is higher than national or regional average. Rate is highest in HoB and BEN areas
HoB and BEN two of highest PCTs in England
Abortions increasing amongst older women
The oral hormonal contraceptive is an effective form of contraception and its popularity reflects the national trend for women selected this as their preferred method of contraception throughout the age groups from under-16-34 years. Locally this deviates once clients reach 35 years of age or older when male condoms become the preferred method of contraception.NICE guidelines states to reduce unintended and unwanted pregnancies that women should be encouraged to move from pills to LARC’s. The graph demonstrates there is a cohort of women, if targeted could save health economy a significant amount of monies and reduce unintended and unwanted pregnancies.
The national target is a 50% reduction in under 18 conceptions by 2010 based on the 1998 data Birmingham has been successful in reducing the under-18 conception rate from 58.3 per 1000 young women 15-17 in 1998 to 43.3 in 2010 ( ONS) this demonstrates a percentage change of 25.7% however it is still some way off the original ten year reduction target of 50%. Teenage Pregnancy continues to be a significant public health issue, however over the last decade there has been significant progress in reducing teenage pregnancy with the rate currently at its lowest level for 30 years. Continued focus is particularly important in Birmingham where the under-18 conception rate is repeatedly higher than both the regional and national average.
The map shows number of teenage conceptions per 1000 population females aged 15-17 between April 2007 and march 2010 by wardBirmingham still has a significant number of wards in the city with unacceptably high rates of teenage age conceptions. At ward level, variations in the under-18 conception rate largely reflects the pattern of deprivation, poor educational attainment and disengagement at schools, with the majority of conceptions occurring in the most deprived wards.The wards that show consistently high over time are Kingstanding, Shard End, Tyburn, Acocks Green, King Norton, Bartley Green, Quintion
Sex and the City
Sex and the 2nd City Liz Altay Consultant in Public Health David WalkerHead of Sexual Health and Teenage Pregnancy Commissioning
Sexual Health• Sexual health and HIV a major public health issue• UK has highest rates of poor sexual health in Europe• Parts of Birmingham very high rates• Increasing STIs, HIV & terminations• Inequalities in sexual health• Preventable
HIV and STI in Birmingham Diagnosis rates of the five main STI diagnoses (GUM only) and HIV* in Birmingham residents, 1996-2011 A B 300 Chlamydia 18 Gonorrhoea 16 Syphilis Genital Herpes Simplex 250 New HIV diagnoses Genital Warts Rate per 100,000 population Rate per 100,000 population 14 200 12 10 150 8 100 6 4 50 2 0 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Episode Year Episode Year * New HIV diagnoses data for 2011 not yet available Please note that the above data does not include non-GUM chlamydia screening resultsSource: HPA – West Midlands STI Surveillance Project; New HIV diagnoses data to end June 2011Data provided by HPA West Midlands Regional Epidemiology Unit
Acute STI diagnosis rates (GUM only) in Birmingham, West Midlands and England, 2009-2011 1400 2009 2010 2011 Rate per 100,000 population 1200 1000 800 600 400 200 0 HoB Sth Bham BEN Birmingham West Mids England Please note that the above data does not include non-GUM chlamydia screening resultsSource: HPA – Genitourinary Medicine Clinic Activity Dataset (GUMCAD)Data provided by HPA West Midlands Regional Epidemiology Unit
Rates of acute STI diagnoses in Birmingham residents (GUM only) by age group and gender, January – December 2011 3500 Female Male Rate per 100,000 population 3000 2500 2000 1500 1000 500 0 <15 15-19 20-24 25-34 35-44 45+ Age at start of episode Please note that the above data does not include non-GUM chlamydia screening resultsSource: Genitourinary Medicine Clinic Activity Dataset (GUMCAD)
Counts and rates of acute STI diagnoses in Birmingham residents (GUM only) by ethnic group and gender, January – December 2011 2500 4500 Female Male Rate per 100,000 population Female Male 4000Count of diagnoses 2000 3500 3000 1500 2500 2000 1000 1500 500 1000 500 0 0 Asian Black Mixed Other White Not Asian Black Mixed Other White specified Ethnic Group Ethnic Group Source: Genitourinary Medicine Clinic Activity Dataset (GUMCAD) Data provided by HPA West Midlands Regional Epidemiology Unit
Diagnosed HIV infected patients accessing care, West Midlands, 2010 Persons with diagnosed HIV accessing care 0 200 400 600 800 1000 1200 1400 1600 Birmingham Coventry Sandwell Wolverhampton Warwickshire Stoke On Trent South Staffordshire Walsall Worcestershire Dudley Shropshire County North Staffordshire Solihull Telford And Wrekin HerefordshireSource: HPA –Survey of Prevalent HIV Infections Diagnosed (SOPHID)Data provided by HPA West Midlands Regional Epidemiology Unit Date Prepared: 02/07/2012
Diagnosed HIV infected patients accessing care by deprivation quintile, Birmingham, 2006 and 2010 80% 2006 2010 Proportion of patients accessing care 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 Most deprived Deprivation Quintile Least deprivedSource: HPA –Survey of Prevalent HIV Infections Diagnosed (SOPHID)Data provided by HPA West Midlands Regional Epidemiology Unit
Abortions All Age Abortion Rate 2010 : Source NCHOD and Local TOPS data Source BSol BI 30 25 20 15Crude Rate per 1,000 Women aged 15-44 10 5 0 ENGLAND AND WALES ENGLAND Heart Of Birmingham Teaching WEST MIDLANDS South Birmingham PCT Birmingham East and North PCT PCT Birmingham local moving average 2008-10
Abortion rate per 1,000 population aged 18-44 by PCT 2010
Teenage Conception Rate per 1000 Females 15-17 years Teenage Conception Rates Birmingham West Midlands England 2010 Target 70.0 60.0Under 18 conception rate per 1000 50.0 40.0 30.0 20.0 10.0 0.0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Source: Birmingham and Solihull Business Intelligence
Number of Teenage Conceptions per 1000 Population Females aged 15-17 between April 2007 and March 2010 by Ward Source: Bham and Solihull Business Intelligence 2012
Teenage Pregnancy Chlamydia Screening Services Programme Termination of Pregnancy ServicesSexual Health Promotion Services Young Peoples Genito-Uriniary Services Services Specialist HIV Treatments Reproductive Sexual Health Services Third Sector HIV Services
Level 3 – Investigation and management of complex STI’s, HIV complexcontraception needs due to other illness. Termination of pregnancies.Vasectomy. Specialist Sexual Health Promotion Level 2 – Psychosexual therapiesLevel 2 – Symptomatic & asymptomatic STI’s. Partner notification. LARC provision Level 2 – services also provide services as outlined in level 1Level 1 – Oral contraception. Condoms. EHC. Sexual Health Promotion.Abortion referral. Vasectomy referral. Full sexual health history andassessment. Screening of asymptomatics for chlamydia and gonorrhoea(GC+ve ref to level2. HIV Testing / ongoing shared care with level 3
Example of integrated service delivery Level 3: investigation and management of complex STIs, HIV complex contraception needs due to other illness. Termination of Pregnancies. Vasectomy. Specialised Sexual Health Promotion Level 2 - symptomatic & asymptomatic STIs. Partner notification. LARC provision Level 2 services also provide services as outlined in level 1 . Psychosexual therapies. Level 1 – Oral contraception. Condoms. EHC. Sexual health promotion. Abortion referral. Vasectomy referral. Full sexual health history andassessment. Screening of asymptomatics for chlamydia and gonorrhoea (GC +ve ref to level 2). HIV testing/ on going shared care with level 3 NB All services to provide SH promotion.
Sexual Health in the 2nd City - What has beenachieved?•10 year national strategy – sexual health , teenage pregnancy, HIVCommissioning – understanding need + local SH strategy•New programmes /partnerships – Teenage pregnancy•NHS Performance framework – KPIs : access to terminations, teenage conceptions and chlamydia•Real growth in range , type , quality of service provision•Increased funding – from £8.78 million [ 2006 ] to £ 20 million plus]•Real Improvements in sexual health outcomes
Sexual Health in the 2nd City - What has beenachieved?25.7% reduction in Teenage conception rates December 1998 and June2012 cf West Midlands (19.4%) : England (20.3] Chlamydia screening coverage [ 15 – 24 yrs ] 29 %- 33% cf national average- 25.2 %50% decline in Gonorrhea rates - 10 years
Sexual Health in the 2nd City - Challenges :• Inequalities in sexual health persist• Distribution of services - not rational /needs led•Quality and range of primary care services – v .variable•Balance of investment [ GUM ] – “downstream “ not prevention•Service provision – separate , parallel , fragmented
Sexual Health in the 2nd City – Determinants ofsexual health• Social deprivation• Ethnicity• Migration• Culture• Service provision + access• Neighbourhoods
Opportunities:Focus on Social Determinants of Health Move away from ‘Deficit’ model of delivery to an ‘Asset ‘ model of delivery •Deficit model – focuses on failure of communities to avoid disease •Asset model - focuses on the potential to create and sustain health
Opportunities:Focus on Social Determinants of Health How ? •As an employer •Through the services commissioned and delivered •Through regulatory powers •Through community leadership •Through localism •Any others?
Sexual Health System• Health Improvement (Public Health lead) • Strategy/Policy • Reducing SH inequalities • Sexual Health promotion/prevention• Health Protection (HPA lead) • Surveillance • Epidemiology • Outbreaks• Sexual Health Service Improvement (Public Health/NHS Cluster) • Commissioning effective services • Audit & evaluation • Clinical Governance
Current commissioned services Level 3 Genito-urinary medicine (GUM) Specialist HIV treatment and care services Complex contraceptive services (provided by acute trust) Abortion services – acute Level 2 Integrated, community based trusts and contraceptive and sexual health Independent services x 2 Clinics Sector. Brook (Young People Focused) GP enhanced, open access services Psychosexual – 2 clinics service GP provision of coil and implants Level 1 GMS/PMS GP services Sexual Assault Chlamydia screening programme Referral Centre Community pharmacy services (SARC) Health promotion Teenage Pregnancy programmes
Sexual Health Responsibilities• LAs will be mandated to commission open access STI testing & treatment and contraception services for all persons present in their area. LAs will commission needs-led sexual health services for its population. The commissioning responsibility will involve holding the ring for an integrated sexual health system, core functions include: – comprehensive needs assessment; – strategy development – sexual health promotion, particularly with high risk groups – health protection in the form of surveillance, epidemiology and the management of outbreaks; – provision of partner notification; – targeted services, including outreach work for high risk groups; – procuring high quality accessible integrated sexual health services; – workforce planning in partnership with training consortia; – monitoring sexual health outcomes.
PHOF Outcomes• Chlamydia diagnoses (15-24 year olds)• Reduction in people presenting with HIV at a late stage of infection• Reduction in teenage conceptions in under 18’s• Indirectly related outcomes: • ante-natal HIV screening • Violent crime (including sexual violence) • Employment for those with a long-term health condition including those living with HIV
Local Authorities will commission Clinical Commissioning Groups NHS Commissioning Board will will commission commissionComprehensive sexual health Fully integrated and comprehensive Contraception provided as anservices, including: termination of pregnancy services – additional service under the GP [but there will be a further contract Contraception, including LESs consultation about the best (implants) and NESs commissioning arrangements in the HIV treatment and care [although (intrauterine contraception) – longer term] work is continuing to determine but excluding contraception whether CCGs should commission provided as an additional Sterilisation some elements of the pathway] service under the GP contract) STI testing and treatment, Vasectomy Promotion of opportunistic testing including post-exposure and treatment for STIs and patient prophylaxis after sexual requested testing by GPs exposure, chlamydia screening as part of the National Chlamydia Screening Sexual Assault Referral Centres Programme and HIV testing Sexual health aspects of psychosexual counselling Any sexual health specialist services, including young peoples sexual health and teenage pregnancy services, outreach, HIV prevention and sexual health promotion work, services in schools, colleges and pharmacies
1st April 2013Level 3 Genito-urinary medicine (acute trust) Specialist HIV treatment and care services Complex contraceptive services (provided by acute trust) Abortion servicesLevel 2 Integrated, community based – Acute trusts and contraceptive and sexual health Independent services: Sector Brook GP enhanced, open access services – 2 Psychosexual clinics service GP provision of coil and implants Sexual AssaultLevel 1 GMS/PMS GP services Referral Centre Chlamydia screening programme (SARC) Community pharmacy services Health promotion Teenage Pregnancy programmes
Sexual Health Commissioning OptionsService Provider Current LAs Contract Clinical Commissioner Contract Commissioner Support Governance post April 13 Support April 13GUM NHS Trust BPH Birmingham,Solihull BSol NHS Cluster BSol NHS Cluster PH in Local CSS Sandwell,Dudley Authority WalsallHIV Treatment NHS Trust NHS Specialised West Midlands NHS Specialised NHS Specialised NHS CB NHSCB/CSS commissioner commissioner commissioner withPH support via core offerIntegrated Sexual NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSSHealth Services Authority rdBrook (Young People) 3 sector BPH Birmingham & BPH BSol NHS Cluster PH in Local LA Solihull AuthorityChlamydia Screening NHS Trust BPH Birmingham & BSol NHS Cluster BSol NHS Cluster PH in Local CSS(under 25s) Solihull AuthorityReproductive Sexual NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSSHealth Services Authority(Contraception)Sexual Health NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSSPromotion/Training Authority rdTermination Services 3 sector BPH Birmingham BPH BSol NHS Cluster CCGs with PH CSS Solihull support via core Shropshire offerEnhanced primary care GPs BPH Birmingham Cluster Primary BSol NHS Cluster PH in Local NHS CBservices Pharmacies Care Authority Commissioners (via NHS CB?) rdHIV Prevention Services 3 sector BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local LA AuthorityPsycho-sexual NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSScounselling AuthorityTeenage Pregnancy NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local LA & CSSprogrammes/services BCC Primary Care Authority Pharmacies BPH rd 3 sectorSARC To be tendered BPH Birmingham,Solihull BSol NHS Cluster BSol NHS Cluster NHS CB NHSCB/CSS Walsall,Wolvs,Dudley with PH support
Proposal• Policy/Strategy – PH core team (LA) & PHE• Needs assessment – PH core team (LA)• Sexual Health Improvement/prevention activity – PH core team (LA)• Sexual Health inequalities – PH core team (LA)• Health protection (surveillance, outbreaks, epidemiology)– PHE with oversight from DPH through Birmingham HP Forum• Strategic commissioning of sexual health services – PH core team – Contract Support for NHS Services – CSS (including Clinical Governance) – Contract Support for non NHS Services – LA (including clinical governance) •Strategic commissioning advice and support to NHS CB and CCGs – PH core team (LA) through “core offer”