surrey sexual health needs assessment - Surrey-i

SURREY
SEXUAL HEALTH
NEEDS ASSESSMENT
October 2008
1
EXECUTIVE SUMMARY
Introduction
This report pulls together a wide range of data and other evidence in order to
assess the sexual health needs of the people in Surrey. The data is analysed and
recommendations are presented on how best we might go about meeting these
needs. To start, the report opens with a profile of Surrey with specific reference to
population health and health inequalities. The report describes the various
methodologies used to collect the data and acknowledges the strengths and
limitations of particular findings. The process of gaining users’ and potential users’
views has been invaluable as it served to foster better relationships with partner
organisations and helped build public awareness of sexual health issues in Surrey.
The main report is split into six discrete sections, the findings of which are
summarised below:
Current Sexual Health and Contraception Services provision in Surrey
This section provides an overview of current services in Surrey. It highlights the fact
that services are, on the whole, well distributed across the county, located in the
most densely populated areas and near to good public transport links. It identifies
rural areas, especially in the South West as having gaps in provision of
contraceptive services, especially for young people. Gaps are also identified in the
provision of psychosexual services, prison services, outreach GUM services,
primary care (GP services), provision of free access to condoms in educational
establishments and the availability of long acting reversible contraception methods
in primary care.
Contraception: Teenage conceptions, abortion data and contraception
services
This section highlights Surrey’s slow progress in reducing its already low-base
conception rate for under 18s compared with that of other similar counties. The
under 16 rate has remained constant which suggests that there has been no real
impact of prevention measures. The boroughs of Spelthorne, Woking and
Runnymede are highlighted as having consistently higher rates than other
boroughs. The borough of Surrey Heath shows the single biggest increase in
conception rates with a 21% increase change in rate between 98/00 and 04/06.
Surrey has relatively high under 18 abortion rates with an average of 60% of
conceptions terminated in the period 2004-6 compared to 47% nationally. The
borough of Runnymede recorded a rate of 72% in the same period.
Prevention messages and contraception services should be developed and better
promoted, especially, but not exclusively, in areas with highest numbers of
conceptions and in areas of relative deprivation. Current access to contraception
services data shows that primary care’s promotion and use of long acting reversible
contraception methods is low compared to that provided by community
contraception services, despite the established advantages of using such methods.
Recommendations focus upon increasing access to contraceptive services, with
particular reference to young people. They also highlight the need for better
promotion and delivery of more reliable methods of contraception such as long
1
acting reversible methods and the provision of free condoms to anyone who needs
them. Participants of the online survey suggested that condoms should be made
available in places where young people can easily access them such as in a range
of educational establishments, town centre shops, pubs, clubs and bars and leisure
services. The development of new local services in areas with greatest populations
and or highest conception rates was the clearest need.
Sexually Transmitted Infections (STIs) and GUM services
Data at Surrey county level compares percentage increases in diagnoses of the 5
key STIs prevalent in the UK and Surrey, notably warts, herpes, Chlamydia,
gonorrhoea and syphilis, with that of the South East Coast (SEC). In the absence of
reliable prevalence rates, this enables a modicum of assessment of disease
prevalence in Surrey. Diagnosed rates of Chlamydia and herpes in Surrey have
gone up at a slightly higher rate than that of the SEC with a 21% and 25% increase
respectively between 2005-6 and 2006-7. Gonorrhoea trends show a slight
decrease, warts have remained stable and syphilis numbers remain very small.
Uptake of Chlamydia screening in the first year of the Surrey Chlamydia screening
programme has been slow with a total of only 2.2% of the target population being
screened, but innovative measures are being taken to increase this over the next
12 months. National rates are only 4.9% and many programmes have been
established over a much longer period.
HIV data highlights gay men and African populations as the two key groups of
people mainly affected by HIV in Surrey, which directly reflects national trends.
Activity and access data for Genito Urinary Medicine Clinics shows considerable
success. In June 2008 Surrey achieved reaching its 100% target of patients who
call for an appointment being successfully offered one within 48 hours. Further
work is under way to increase the percentage of patients seen within 48 hours.
Key recommendations focus upon increasing publicity and promotion of GUM
services and continuing to dispel negative myths about sexual health screening,
confidentiality and access to female doctors, increasing the number of outreach
outlets that can provide STI screening with particular attention to improving access
to working people, sex workers, gay men, Black and Minority Ethnic (BME) groups
and vulnerable groups. More screening of asymptomatic STIs need to take place
outside GUM including the piloting of one-stop-shop approaches (contraception
and STI screening together) which is evidenced based and recommended.
Other sexual health issues
Groups of people who are considered to be at greater risk of having poor sexual
health and / or require additional support to access services include older people
and their access to psychosexual services, people with learning disabilities and
mental health problems, sex workers, black African populations, especially women,
the prison population of both sexes, men who have sex with men and young
people. However, there are dedicated services that are currently working with some
of these groups; notably the Surrey Community Health Services Harm Reduction
Outreach Team, Terrence Higgins Trust and African Families Support Services.
Some sexual health services are being provided in prisons but there are still gaps
at Send and Bronzefield prisons. It is recommended that separate needs
assessments are undertaken with some of these particular groups of the population
in order that mainstream services can be tailored to cater better for their needs.
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Access to future contraceptive and sexual health services
This section highlights a range of suggestions offered up by participants of the
online survey about improving access to services. Key themes include extending
opening hours to include Saturday morning clinics or after work clinics aimed at
adults over the age of 19, enabling greater choice of contraception methods
through primary care, promoting services more keenly using social marketing,
locating services in town centres and near to public transport and making them
anonymous. There was general consensus about the positive value of setting up
one-stop-shop sexual health and contraception services.
Other reviews of Surrey sexual health and contraceptive services
This section provides an overview of several other recent evaluations and reviews
that have been conducted in Surrey. Firstly, the evaluation of the young people’s
community based sexual health service, “Monday 4U” in Redhill underscores the
value of this type of service and highlights the potential for replication, but only in
areas where demand for such services is high. Secondly, feedback from two
different reviews of the Surrey Teenage Pregnancy Strategy, the Joint Area Review
(JAR) and the National Children’s Bureau (NCB) evaluation, which draw mainly
upon the opinions of professionals in the field, provide another useful dimension for
this assessment of need. They offer up a host of specific recommendations too
numerous to mention here but which reflect, on the whole, the recommendations
already identified. Thirdly the national evaluation of ‘one-stop-shop’ sexual health
services serves to support recommendations for similar service development in
Surrey. Its recommendations include the development of a hub and spoke model of
service delivery for both contraceptive and sexual health (GUM) services. This
appears to be both a pragmatic and appropriate move for Surrey and one that is
potentially achievable.
The next steps
This concluding section suggests that services need to be developed in a way that
reflects the holistic nature of sexual health. Recommendations put forward in this
report will be explored further at the first Surrey-wide sexual health services
‘Visioning’ event to be held in October 2008 at which key Surrey Stakeholders are
invited. From this, the Surrey Sexual Health Strategy and Acton Plan will be
modified and a commissioning framework devised. It is hoped that any actions
undertaken will continue to improve Surrey’s record of providing excellent sexual
health services. To quote a respondent from the online survey:
“Despite it being a really worrying time I felt really cared for. I think that the staff did
a good job in helping me through things. All I want to say is thank you.”
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Contents
Page
1.
Introduction and rationale
1. 1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
Introduction
Rationale for conducting the assessment
Policy drivers and reviews for improving sexual health
How the needs assessment was developed
Model for identifying need
Methodology
Gathering users’ and potential users’ views
The ‘It takes you to Tango’ online survey
Promotion and Publicity of the survey
Survey response and methodology of data analysis
Conducting focus groups with young people
2.
Needs in context
2.1
2.2
2.3
Population profile of Surrey
Health Inequalities
Migration
3.
Current Sexual Health and Contraception Service
Provision
3.1
3.2
3.3
3.4
3.5
List of current services
Diagram of current service groupings
Geographical distribution of sexual health services
Map of population density
Sexual Health Services across Surrey (by level of service: defined
by National Sexual Health Strategy)
Summary of contraception and sexual health services in Surrey and
a gap analysis
3.6
6
6
6
7
8
8
8
8
9
10
10
11
13
15
4.
Contraception and Contraception Services
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Teenage Pregnancy
Termination data
Provision of contraception
Users’ and potential users’ views
Users’ views about LARC
Users’ views about condoms
Recommendations
5.
Sexually Transmitted Infections
5.1
5.2
Morbidity
Analysis of STI cases
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19
20
21
22
25
26
32
36
39
40
41
42
43
46
4
5.3
5.4
5.5
5.6
5.7
5.8
Chlamydia screening
HIV infection in Surrey
Genito-Urinary Medicine (GUM) activity
GUM access
Users’ and potential users’ views about STIs
Sexual Health Services (GUM): Recommendations
6.
Other Sexual Health Issues
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
Psychosexual problems
Users’ and potential users’ views
Sexual Health Promotion
People from black and minority ethnic communities
Sex workers in Surrey
People with learning disabilities and mental health problems
Prison populations
Men who have sex with men
Users’ and potential users’ views
Recommendations
7.
Access to Future Contraception and Sexual Health
Services
7.1
7.2
7.3
Users’ and potential users’ views about futures services
Access to one-stop-shops
Recommendations: Access to future services
8.
Other reviews of Surrey sexual health services
8.1
8.2
8.3
8.4
8.5
Surrey PCT reconfiguration
Monday 4U service evaluation
Feedback from the Joint Area Review (JAR)
Feedback from the National Children’s Bureau evaluation
Evidence base for the development of One-stop-shops
9
Next Steps
9.1
9.2
Stakeholders’ involvement
Contributors to the needs assessment
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48
49
54
56
57
58
59
59
60
60
61
61
62
63
64
66
67
67
69
70
70
70
70
72
73
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1. Introduction and rationale
1.1. Introduction
Our intention in this report is to present a variety of data in a clear, user friendly and
easily readable way. We aim for the analysis to be as transparent as possible, the
recommendations to draw upon sound evidence and to truly reflect people’s views.
We plan to keep the document concise. In this report the reader is provided with a
summary of the data, a summary of analysis and salient points and
recommendations are highlighted. Detail is provided in the form of a supporting
document, which is attached as an appendix.
1.2 Rationale for conducting a needs assessment in Surrey
Sexual health is viewed by the Department of Health and the Health Protection
Agency as an important public health challenge both nationally and in Surrey.
Understanding this challenge and making plans to meet it requires a robust picture
of what it looks like. Mapping provision of sexual health services against
prevalence, population and burden of disease was an important first step for Surrey
and a Health Equity Audit (HEA) was undertaken by the PCT in 2007. From this,
the Surrey Sexual Health Strategy was developed, the purpose of which was to
outline achievable and measurable plans to support improvements. Dove-tailed to
the strategy will be the development of a commissioning framework that also
reflects Surrey Primary Care Trust’s (SPCT) commitment to target resources at
greatest need, extend areas of best practice and harness service providers’ desire
to deliver quality, sustainable services. The Needs Assessment not only captures
the views and opinions of Surrey people, especially those who are not currently
accessing services, but it also draws upon a range of evaluations and assessments
that give greater depth of evidence. It is only by assessing these entire aspects can
the Surrey Sexual Health Strategy be modified and a commissioning framework
developed to meet these needs.
1.3 Policy drivers and reviews
The following policy documents have shaped the focus of this Needs Assessment.
- The National Sexual Health and HIV Strategy1
- NHS ‘Vital signs’ targets (chlamydia screening, reduction in teenage conceptions)2
- Health Care Commission Standards (48 hours Genito Urinary Medicine Clinic
Access standard)3
- Choosing Health (DH Policy document)4
- National Institute for Health and Clinical Excellence guidance on Long Acting
Reversible methods of Contraception (LARC)5
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- Recommended Standards for Sexual Health Services6
- Evaluation of One-Stop-Shop Models of Sexual Health Provision7
- Joint Area Review (review of teenage pregnancy) for Surrey8
- National Children’s Bureau Evaluation of the Surrey Teenage Pregnancy Strategy
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1.4 How the needs assessment was developed
The development of the Surrey Sexual Health Needs Assessment (SHNA) was
initiated and overseen by the Surrey Sexual Health Strategy Group. This group
has diverse multi-agency and multi disciplinary membership. The approach to this
assessment is based on DH guidance on how to undertake a sexual health needs
assessment10. Smaller task groups were also set up to develop the public
questionnaire, design the publicity and support data analysis.
1.5 Model for Identifying Needs
The model illustrated below shows what the demands on services are and what
services are currently being provided. From this it is possible to identify gaps in
service provision and make recommendations accordingly.
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1.6 Methodology used
The assessment used a variety of methodologies to help provide a rich picture of
the sexual health needs in Surrey. The triangulation of data sources,
epidemiological data, service data, users’ and potential users’ views and
stakeholders’ views ensures that a robust assessment is made.
1.7 Gathering users’ and potential users’ views
In recent years there have been a number of other surveys undertaken in Surrey on
the use of sexual health services. For example, in East Surrey an audit of access to
the GUM clinic was conducted in 2007 the results of which have been incorporated
into the recommendations in this report. However, the most challenging aspect of
any health needs assessment is gaining the views of people that do not currently
access services. This is particularly pertinent to sexual health as the nature of the
subject is sensitive and it can be difficult for some people to discuss sexual health
issues through face-to-face interactions. Thus, a creative approach was required
and the decision made to develop an online questionnaire. This method served the
dual purpose of maintaining people’s confidentiality and enabled people to remain
anonymous by avoiding face-to-face contact. It was also thought that such an
approach would facilitate greater ease of access to the survey than a paper survey.
However, to further extend access, paper questionnaires were developed and
distributed (with a freepost envelope) for those who cannot easily access the
Internet or find filling in an online survey difficult. Young people were identified as a
particularly vulnerable group, especially in relation to this topic, as it is well
documented that young people find it difficult to discuss sexual health issues on a
one to one basis. Focus groups are regarded by young people and many in the
field as acceptable and were used to gain their thoughts and opinions.
In total, the views of nearly three hundred people were captured. Due to the selfselecting nature of this methodological approach and the relatively small numbers
of views that were actually gathered, it is important to acknowledge that the online
survey results cannot be regarded as a representative sample of all people that live
in Surrey. However, 300 people have given up their time to convey their opinions
and we feel that it is important that these views are incorporated into the findings
and used to help make appropriate recommendations.
1.8 The ‘It takes you to tango’ survey
The online questionnaire was
developed by a multi-agency group
of professionals. A fundamental
principle behind designing the
questionnaire was to ensure the
validity of the survey results. Each
question was carefully considered
to ascertain that it would gain the
required information.
8
Mixtures of open and forced compliance questions were used. Computer ‘popups’ were developed and inserted throughout the questionnaire to enable
users to get full explanations of what is defined as sexual health, sexual
health services, GUM, different contraception methods and sexual problems.
It was piloted with members of the public and with a range of health care
professionals. Amendments were made in accordance to these findings and
the final questionnaire was launched online on June 9th 2008 through the
SPCT website. The questionnaire went online for 6 weeks.
The survey itself was branded with the slogan ‘It takes you to tango’ giving it a
catchy turn of phrase that we hoped would engage the public. A promotional
postcard was designed in partnership with a graphic design company and the
SPCT Communications Team. A group of Public Relations Officers from the
different borough councils and partnership organisations across Surrey were
also consulted. The survey was incentivised with cinema tickets to help to
stimulate interest.
1.9 Promotion and Publicity of the Survey
A wide reaching publicity campaign was launched to promote the survey.
Meetings were held with officers from Surrey County Council and the borough
councils to gain their support to publicise the survey. Heavy reliance was
placed upon these partner agencies and organisations to promote the survey
through their staff newsletters, staff intranet servers and public websites and
newsletters. This was to ensure large numbers of employees of different sex,
age and social class could be encouraged to complete the questionnaire
online at their work places. A large pharmaceutical company employing
thousands of Surrey residents also supported the promotional drive with their
workforce.
Numerous press releases via local media, including Surrey-wide media and
local media groups were published. Two radio interviews were broadcast
through local radio and 20,000 promotional postcards were distributed across
the county to outlets where it was likely that the public would have access.
Certain services were targeted to gain maximum impact with vulnerable
groups such as teenage parents, young people, young people in or leaving
care, HIV positive service users, drug users, people with physical and learning
disabilities and mental health problems. NHS services were also targeted
such as GP surgeries, hospital foyers and all 32 sexual health services.
Borough council buildings, libraries, sixth-form colleges, Further Education
colleges and Surrey University were also provided with postcards and
promotional press releases to use on their intranets. Indeed, many individuals
and partner organisations went out of their way to support their service users
to access the questionnaire.
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1.10 Survey response and methodology of data analysis
A total of 353 people attempted to complete the survey, 281 went on to submit
the survey (partly due to technical issues) and 277 were used for the analysis
after the data was ‘cleaned’ by removing duplicate or corrupt data.
Significance testing was not applied due to the small sample size and
sampling methodology. To help increase internal validity, the data obtained
was analysed using SPSS (Statistical Package for Social Sciences). This also
enabled cross tabulation of results of specific questions, such as those
comparing specific responses to people’s age and gender.
The qualitative questions were analysed based on Miles and Huberman’s
(1994)11 view that data analysis consists of three stages. The first is data
reduction, which consists of selecting, simplifying and abstracting the
qualitative comments. The second is data display, which organises the data
into an inductive coding frame so that it can be understood and key themes
identified. The final stage is re-coding the data into the coding frame to draw
conclusions and subsequent recommendations. The result is that key themes
can be put forward and the strength of these themes (how many people
described them) can be demonstrated. Together with the themes identified,
typical quotes are used to illustrate the findings.
1.11 Conducting the focus groups with young people
Two focus groups were held comprising a total of 14 young people aged
between 16 and 18 years old. Focus Group 1 was a mixed group of 5 young
women and five young men. All lived in the borough of Guildford and had
been brought together through the Guildford YMCA voluntary youth group.
They were an established group and the young people had known each other
for several weeks. In this respect they were comfortable talking about sexual
health with each other. Prior to the focus group convening the Group had
invited a speaker from the Surrey Chlamydia Screening Programme to talk to
them about the scheme, which opened up a natural pathway for engaging in a
focus group about sexual health services. This focus group lasted for 55
minutes. The questions asked were based on the ‘It takes you to tango’
survey but were modified to make them more young people friendly. The
young people were lively and very participative. One young woman was a
teenage mother.
Focus Group 2 comprised of 4 young men from 4 different districts of the
county including Godalming, Guildford, Ashford and Staines. This group were
also familiar with each other and had been working together on a group
activity for several weeks. They were all part of the Surrey Youth Justice
Service. Two staff members also participated and supported the facilitation of
the discussion. All the participants were attending a summer programme of
educational and recreational activities and the focus group served as an
element of their educational programme. This was billed as providing them the
opportunity to understand the process of public engagement. All the young
men were happy to participate in the focus group and appeared to enjoy the
opportunity to discuss the topic.
10
The focus groups were conducted by 2 public health leads and tape recorded
to help ensure that all points were captured accurately. This was done with
the participants’ signed consent. The data was analysed using the same
inductive coding frame utilised for the qualitative aspects of the online survey.
A full report of the findings of the survey and focus groups can be found in
appendix 1. There is an ongoing intention to conduct more focus groups with
other groups of young people in the near future.
2. Needs in context
2.1 Population profile of Surrey
Surrey has over one million people living in eleven boroughs, which together
form the North West, South East and South West localities of Surrey PCT.
Table1. Surrey population numbers per 1000 by age group compared with England
Population Numbers (Thousands)
Age
Surrey
Male
0-4
5-9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 +
Total
Female
England
Female
Males
s
Population Percentages
Surrey
Male
England
Female
Males
Females
32.2
31.3
1,513.1
1,442.3
6.1
5.6
6.1
5.6
33.4
31.3
1,493.2
1,428.4
6.3
5.6
6.0
5.5
34.8
32.5
1,606.4
1,523.3
6.6
5.8
6.4
5.9
34.8
32.1
1,719.6
1,614.8
6.6
5.8
6.9
6.3
28.1
28.4
1,712.7
1,648.9
5.3
5.1
6.9
6.4
30.9
32.0
1,636.7
1,634.6
5.9
5.7
6.6
6.3
34.1
36.4
1,716.0
1,720.9
6.5
6.5
6.9
6.7
40.9
44.1
1,934.3
1,946.8
7.7
7.9
7.8
7.5
44.5
46.2
1,940.8
1,970.7
8.4
8.3
7.8
7.6
39.1
39.6
1,717.9
1,738.7
7.4
7.1
6.9
6.7
34.5
34.3
1,512.7
1,547.0
6.5
6.2
6.1
6.0
36.2
37.3
1,608.4
1,652.2
6.9
6.7
6.5
6.4
29.1
30.2
1,320.2
1,376.6
5.5
5.4
5.3
5.3
21.8
24.3
1,074.9
1,155.8
4.1
4.4
4.3
4.5
19.2
22.5
905.9
1,034.7
3.6
4.0
3.6
4.0
15.5
20.0
713.8
923.7
2.9
3.6
2.9
3.6
10.8
16.9
476.1
746.0
2.0
3.0
1.9
2.9
8.1
18.0
731.2
1.5
3.2
1.3
2.8
528.0
557.2
323.7
24,926.
4
25,836.6
100.0
100.0
100.0
100.0
11
Table2. Resident Population in Surrey by localities (mid-2004 & 2007)
Locality
Boroughs
Population (2004)
Population (2007)
Runnymede
78,500
79,400
Spelthorne
88,400
87,300
Elmbridge
127,500
135,000
Woking
89,600
91,100
Surrey Heath
81,100
82,200
Guildford
130,700
133,600
Waverley
116,300
116,600
Epsom & Ewell
68,000
69,400
Reigate & Banstead
126,900
128,500
Tandridge
79,300
80,000
Mole Valley
80,900
81,600
1,067,200
1,084, 800
North West
South West
South East
Total
Source: Office of National Statistics: National resident population projections (2004, 2007)
The mid-2007 population is the latest projected estimate of Surrey’s
population, citing an overall increase of 15,000. The North West locality has
the largest population and the South West locality has the smallest. Elmbridge
is the largest local authority, which together with Guildford and Reigate &
Banstead constitutes more than a third of the population resident in Surrey.
This highlights that there are large rural areas in Surrey which in itself can
pose particular problems for providing specialist sexual health services where
need is considerable for the people who live there but demand on services is
comparatively low.
The population pyramid in figure 1 below shows that Surrey is a
predominantly ‘middle aged’ county with the biggest population in the 35-49
year age group. Surrey has similar numbers of young men and women aged
5-19 years, but significantly fewer people aged 20-29 years. This may reflect
young people leaving the county to go to college or university or to find work
in London or else where. These demographics suggest the need for sexual
health services to cater for the younger age groups up to 19, where demand
may be greatest, especially for those in the 16-19 year age group.
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Figure1. Population pyramid for Surrey showing age distribution by sex
85 +
80 - 84
75 - 79
70 - 74
65 - 69
60 - 64
55 - 59
50 - 54
45 - 49
Age
40 - 44
35 - 39
30 - 34
25 - 29
20 - 24
15 - 19
10 - 14
5-9
0-4
10
8
6
Males
4
2
0
2
% of total population
4
6
8
10
Females
2.2 Health Inequalities
The county of Surrey has a diverse environment with a mix of rural and urban
areas. While overall the population is affluent in comparison to the national
average, there are masked pockets of deprivation and inequalities present
across Surrey. The Index of Multiple Deprivation (IMD) is a national index that
identifies the spread of relative deprivation by local authority, electoral ward
and “super output areas”. The LA boroughs across the whole of England have
been ranked according to this index. Using the IMD 2007 to assess Surrey,
Spelthorne has the largest proportion of the population living in areas that are
ranked in the quintile that is amongst the most deprived in England. Woking,
Epsom & Ewell and Reigate and Banstead boroughs follow this with a greater
proportion of people living in low-income households.
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Figure2. Distribution of Surrey and England’s population in relation to IMD score quintiles, 2007
1
England Quintile
2
3
4
5
100%
90%
Proportionof total population
80%
70%
60%
50%
40%
30%
20%
South East
Surrey
Waverley
Surrey Heath
Guildford
Tandridge
Banstead
Reigate and
Mole Valley
Epsomand Ewell
North West
Woking
Spelthorne
Runnymede
0%
Elmbridge
10%
South Wes t
Source: Ministry for Communities and Local Government
Guildford, Waverley and Elmbridge boroughs have the highest population of
young people (15-19 years old), which may be reflected in the demand for
more young people’s contraception and sexual health services in these areas.
In general, however, there are greater numbers of older people (65+ years)
living in Surrey than in England. This population group is projected to grow by
17% in 2011. At present the biggest proportion of older people (65+ years)
live in the borough of Waverley but their numbers are reflected across the
whole of the county. The effect of an aging population has the potential of
impacting upon demand for psychosexual services, where numbers of sexual
function problems related to age and age related use of medications is noted.
These issues can easily be overlooked because of the social stigma attached
to them and people’s general reluctance to come forward to ask for support
and help with these matters. This perhaps was reflected in the general low
responses to questions about sexual problems recorded in the online survey.
The number of people from black and minority ethnic (BME) groups in Surrey
has increased as a proportion of the total population. A figure of 3% was
recorded in 1991 but rose to 5% in 2001. There was a further increase to an
estimated 6.8% in 2004. The incidence of sexual health issues amongst BME
groups in Surrey has not been identified by this needs assessment but it is
recognised that our biggest BME population living in Woking borough has a
comparatively lower prevalence of teenage pregnancy compared to other
areas in England. However, prevalence of new HIV diagnoses in the black
African population in Surrey is disproportionately higher than that of the white
population. The use of sexual health services by those belonging to BME
groups may differ according to their attitude and preferences, so it is important
to consider this when planning equal access and opportunity for service users.
14
2.3. Migration
Map 1 shows migration into the South East per 1,000 population from mid
2001 to mid 2006. This indicates that Surrey experiences substantial rates of
migration. The HPA/South East Public Health Observatory suggests that
higher rates of migration are generally seen in urban areas and those that
have colleges or universities. Migration, whether national or international, is
associated with an increase in sexual risk at population level, as this is
associated with a higher number of partner changes. Those who have
migrated, whether for education, work, or in refuge from conflict, are
particularly in need of easily accessible services for contraception and STIs.
Map1 :
Volume of all
migration per
1,000
population Mid2001 to Mid1,2
2006
Source: Office of
National Statistics
Reproduced
with permission
from Health
Protection
Agency & South
East Public
Health
Observatory
(2008) Sexual
Health in the
South East.
1. Volume of migration per 1,000 population is calculated as (in migration + out migration)/population*1000 (for all
migration). 2. Internal migration into and out of higher level areas is not the sum of numbers moving into or out of
component lower level areas, as some migrants move between lower level areas as well. (Data obtained through the
Office of National Statistics).
Young people (U18s), young adults (18-24 years), gay, bisexual men, and
men who have sex with men, HIV positive people, people from BME
populations, looked after young people, sex workers and prison populations
are subgroups with specific needs in the context of sexual health. Their needs
merit special consideration in order to achieve horizontal12 as well as vertical
equity13 across the county for sexual health services.
15
3. Current Sexual Health and Contraception Services
provision in Surrey
It is important to recognise that the term sexual health service has come to
mean different things to different people over time. For the purpose of this
needs assessment a sexual health service has been defined as one that
provides GUM services, such as testing and screening for STIs including HIV,
and provides medical support for people living with HIV. A contraception
service is one that provides a full range of contraceptive and family planning
methods. Recently, services in Surrey have been renamed as Contraception
and Sexual Health Services, otherwise known as CASH services, which offer
contraceptive services with basic STI screening. This is not to say that GUM
services do not offer some elements of contraception and visa versa, but on
the whole they have predominantly provided services within their own
specialisms. A sexual health service does not relate to the provision of sex
and relationship education in schools by schools nurses or by specialist
nurses working with ‘Looked-After Children’. This work would be considered
as sexual health promotion. However, where it is permitted, school nurses do
provide condoms and some emergency hormonal contraception and this is
referred to as a service.
3.1 List of current services
This list, A-J, pertains to the diagram of services on page 17.
A. Genito Urinary Medicine (GUM) Clinics
There are 5 main GUM clinics in Surrey. The Blanche Heriot Unit at St Peter’s
Hospital and Frimley Park Hospital GUM Clinic are both provided by their
respective Acute Trusts. Farnham Road Hospital GUM Clinic (Guildford),
Leatherhead Hospital GUM Clinic and East Surrey Hospital GUM Clinic are all
provided by SPCT provider arm (Surrey Community Health Services). East
Surrey Hospital also provides an ‘Outreach’ GUM service in Horley and the
Blanche Heriot Unit provides an ‘Outreach’ service delivered in partnership
with the Youth Development Service at the Addlestone Youth Centre.
B. Primary Care Services
There are 141 GP surgeries. Two practices have GPs with Special Interest
Clinics in sexual health (GPSI); one based at Weybridge Health Centre and
one at the Stanwell Road Surgery, Spelthorne. There are 109 practices that
provide coil fits through a locally enhanced service agreement with the PCT
and 123 have locally enhanced service agreements for minor surgery that
includes contraceptive implants and injections.
C. Community Contraceptive and Sexual Health Clinics for people of all
ages
There are 23 different contraception clinics available to people of all ages,
which provide the full range of contraceptive methods. All provide screening
for chlamydia and most will provide screening for Gonorrhoea and other STIs
if this is appropriate.
16
D. Community Contraception and Sexual Health Clinics specifically for
Young People
There are 11 clinics specifically targeted at young people available across the
county but many only offer limited sessions on a weekly or bi weekly basis.
Epsom clinic, however, is a positive model and is open Mon-Fridays. All of
these services are part of the Surrey Chlamydia Screening Programme and
offer Chlamydia screening and some other sexual health services.
E. Termination of Pregnancy Providers.
There are 2 key providers: The British Pregnancy Advisory Service (BPAS)
and Marie Stopes International (MSI). The BPAS offers full service access at
any one of their services. In the last year Surrey residents have accessed
services in Twickenham, Brighton, Basingstoke, Bournemouth, LeamingtonSpa and two different clinics in London. Surrey residents currently access full
Marie Stopes services in South, West and Central London and a consultation
service only in Woking. MSI clients also offer patients the choice of telephone
consultations, which take place from their own home. St Peter’s Hospital NHS
Trust has some limited provision. Ashford and St Peter’s is the only provider
of services in Surrey. Referrals are made by primary care and sexual health
practitioners. Post termination support is provided by BPAS and MSI.
F. Chlamydia Screening Programme
A central team provided by Surrey Community Health Services runs the
programme. The programme is for young people aged 24 and under and
there are now 207 screening venues dispersed widely across the county in a
variety of settings. These include: Army barracks, youth centres, schools,
colleges and a variety of different outreach workers from different
organisations. There are also 80 GP practices currently signed up to the
scheme. Young people can also request screening packs via the post.
G. Non NHS and Multi-Agency Community Provision of Sexual Health
Services
A wide range of sexual health advice, information and support is provided by
non-NHS organisations such as the Terrence Higgins Trust, Positive Action,
St Peter’s House Project and the African Families Support Services. In
addition to the Monday 4U young person’s service in Redhill a similar project
runs out of the Connexions Centre in Staines and there are 2 community
contraceptive services provided in partnership with the Youth Development
Service; one is based at the Sheerwater Youth Centre and one at the
Addlestone Youth Centre. The Surrey ‘Get it On’ condom distribution scheme
is currently provided through 50 outlets across Surrey though some of these
are NHS service providers. Psychosexual and relationship counselling is
provided by RELATE.
Hi. NHS Community provision of sexual health services
There are 413 schools in Surrey of which 53 are secondary schools. School
nurses can provide educational in-put into sex and relationships education in
schools but capacity restricts their availability for this kind of work. A few
nurses are able to provide drop in services but only a very few provide
17
emergency hormonal contraception on site. A 2008 survey conducted by the
National Children’s Board of Surrey schools identified that 25% of them did
not have school-nursing support at all.14 Health visitors provide contraceptive
advice to parents and the Harm Reduction Outreach Service provides sexual
health promotion interventions with men who have sex with men (MSM) and
sex workers. Psychosexual services are provided via a primary care service
in Redhill, a community contraceptive clinic in Woking and through the Surrey
and Borders Partnership Trust (SABT), although this contract ceases in
October 08.
Hii. Specialist NHS provision of community sexual health support
Specialist Nurses, such as Looked-After Children’s Nurses (LAC), work
directly with young people in care. A large part of the role is to liaise with
other agencies, for example, school nurses, specialist sexual health staff,
leaving care and family planning practitioners, CAMHS, health visitors and
foster carers. There are 3.5 (whole time equivalent) specialist nurse posts in
Surrey.
J. Community Pharmacists
There are 207 pharmacies in Surrey. To date over 150 pharmacists have
accessed training to accredit them be part of the PCT scheme to provide free
Emergency Hormonal Contraception (EHC) to young people under 21 through
a Patient Group Direction (PGD). A total of 100 pharmacies remain eligible
and 57 pharmacies are currently providing. It is anticipated that by the end of
September 2008, 75% of all pharmacies will have a pharmacist accredited to
provide these services. There are plans underway to enable pharmacists to
offer chlamydia screening and treatment under a local enhanced service.
K. Walk-in Centres and A&E- Provision of Emergency Hormonal
Contraception
There are four NHS walk-in Centres at Woking, Weybridge, Guildford and
East Surrey which all offer EHC out of hours and at weekends. Most A&E
centres will also provide EHC if necessary except Ashford and St Peter’s
Hospital A&E Department.
The following diagram shows the current grouping of services in Surrey.
18
3.2. CURRENT SEXUAL HEALTH SERVICES IN SURREY
G
B
PRIMARY CARE
SERVICES
MULTI-AGENCY COMMUNITY
PROVISION
F
Condom distribution scheme
Youth Development Service
Surrey Healthy schools
Voluntary sector
Mondays 4 you/
Connexions Centres
CHLAMYDIA SCREENING PROGRAMME
H
Specialist NHS COMMUNITY PROVISION
School Nurses, LAC Nurses, Health Visitors,
Psychosexual, Counselling, Outreach service.
I
COMMUNITY
PHARMACISTS
A
GENITO URINARY
MEDICINE CLINICS
E
TERMINATION SERVICES
British Pregnancy Advisory
Service, Marie Stopes
Ashford and St Peter’s Hsp
J
WALK IN CENTRES
and A&E providers of
EHC
C
COMMUNITY CONTRACEPTIVE AND SEXUAL
HEALTH CLINICS (CASH) CLINICS
Care Pathway
19
D
YOUNG PEOPLES COMMUNITY
CONTRACEPTIVE AND SEXUAL HEALTH
CLINICS (CASH)
3.3.
Map 2. Geographical distribution of sexual health services (as of March 08)
Note: Additional pharmacists recruited not shown on this map
20
3.4. Map 3. Population density
21
3.5. Table 3. Sexual Health Services across Surrey (by level of service: defined by National Sexual Health
Strategy)
Description of Service
General
Practice +
GPSI
(Adapted from National Strategy for Sexual Health and HIV)
Community
Contraception
and sexual
health Clinics
Sexual
Health (GUM)
clinics inc
Provider
Acute
Voluntary
Sector
providers
LEVEL 1
Sexual history taking (All practitioners)
Generic information for STI prevention/safer sex advice
Information re local GU provision
Information about the full range of contraceptive methods and where these are available
First prescription and continuing supply of oral contraception (combined + progestogen-only)
3 only
First prescription and continuing supply of injectable contraception
Emergency oral contraception
IUD/IUS routine follow-up
Enhanced service
Referral for female sterilisation
Referral for vasectomy
Assessment and referral for psychosexual problem
8?
Pre-conceptual advice/provision of folic acid
Counselling/screening for genetic disorders (sickle, thalassaemia, CF etc)
Primary investigation of menstrual disorders
Free NHS pregnancy testing and appropriate referral
Limited access
Estimation of gestation (VE or U/S)
Referral for antenatal care
Testicular examination
Referral for Termination of Pregnancy assessment
Cx cytology for screening programme
Referral for colposcopy for abnormalities from routine screening
Hepatitis B screening and immunisation
Chlamydia screening(urine) – men and women
6.
22
Outreach or
other
HIV testing and counselling (with referral pathways)
6. willing
provider:
Testing symptomatic women for STIs (Gonorrhoea, chlamydia, TV)
Gonorrhoea,
Chlamydia only. Will
be referred to GUM
for care
Sexual Abuse – assessment and referral
First episode herpes – assessment and referral
On-going supply of condoms for safer sex/contraception
Not every practice
Genital Warts – assessment and referral
Substance misuse history (inc. Injecting Drug Use)
Hepatitis C testing and counselling (with referral pathways)
Appropriate management of vaginal discharge
Men with symptomatic STIs – assessment and referral
Awareness of local voluntary sector sexual health providers, referrals
Recognition, assessment and onward referral re: Female Genital Mutilation
LEVEL 2
Problems with choice of contraceptive methods
Investigation and treatment of problems with oral contraceptives
Cu and medicated IUD insertion
Enhanced service
Emergency IUD insertion
Enhanced service
St peters?
Diaphragm fitting and follow-up
Contraceptive implant insertion and removal
Enhanced service
Screening asymptomatic women for STIs
Chlamydia and
gonorrhoea
6. Chlamydia
Screening asymptomatic men for STIs
Chlamydia only
6. Chlamydia
Contact tracing/partner notification
to be developed
Management psychosexual problems
Some psychosexual
counselling at
Redhill
Management organic sexual dysfunction
To be confirmed
Assessment for TOP (self referral)
Some psychosexual
counselling at
Woking and Epsom
Inc nurse referral
Treatment of first episode herpes
Treatment of genital warts (+ ref for all modalities)
23
Relate
Tests of cure STIs (when appropriate)
Management of recurrent herpes (including suppressive Rx) and initiation of suppressive treatment
To be confirmed
LEVEL 3
Outreach services for STI prevention/contraception
Prevention work in
schools and colleges
4?
Colposcopy and out-patient treatment
Prevention
only
10. MSM, IDU,
Sex workers
3. & 4
Specialised HIV services
11
Local co-ordination and specialist back-up for sexual assault including forensic sciences
4.
Vulval diseases (specialist dermatologist services)
3 & 4 only
Penile dermatoses (specialist dermatological services)
4 only
Specialist STI services (e.g.: Syphilis, recalcitrant TV, problem warts/HSV/recurrent NSU)
STI services for groups with special needs (e.g.: gay men, young people, some black and ethnic
minority populations, sex workers)
IUD/IUS problem clinics
Specialist contraception services (e.g.: new modalities, services for groups with special needs
(young people, some black and ethnic minority populations, those with complex problems)
Key: GUM clinics 1= Farnham Rd GUM clinic, 2 = Leatherhead GUM clinic, 3 = East Surrey GUM clinic, 4= Blanche Heriot GUM, 5 = Frimley Park GUM clinic
Voluntary Sector: 6= Terrence Higgins Trust, 7= Positive Action, 8= St Peters House Project, 9= African Families Support Services
Outreach/Other Services: 10 = Harm reduction outreach Service, 11 = Clinical Nurse Specialists, 12 = Monday 4U, 13 = pharmacies, 14 = Walk-in
Note: Audit of GP services to be undertaken to confirm exact services provided.
24
3.6 Summary of contraception and sexual health services in Surrey and
a gap analysis
Generally, contraceptive services and sexual health services (GUM clinics)
are currently well distributed across Surrey. Map 2 shows the geographical
distribution of all of Surrey’s services and Map 3 show how these services are
appropriately located in areas of dense populations.
There are several gaps in service provision in Surrey. In South West Surrey,
there are large rural areas outside of the town of Guildford which require
travelling considerable distances from some villages and towns for people to
access key mainstream services located in Guildford town. There is also a
lack of non-GP provided contraception services, particularly for young people
in these rural areas. It is for these reasons that mainstream services need to
be located in places where there are good transport links.
Across the whole county there is a general lack of psychosexual therapy
services. The service provided by Surrey and Borders Partnership Trusts is
being de-commissioned. Other provision is limited to two GP practices that
offer counselling which address marital and relationship sex therapy. These
are in Woking and Redhill but which leave vast swathes of the population with
no service provision at all or they are required to travel long distances to reach
private services. People have access to ‘Relate’ psychosexual counselling
and therapy but this is provided by a privately run organisation that offers
therapy for a fee, albeit on a sliding scale based on ability to pay. Anyone can
access this service without referral. There is a modicum of management of
organic sexual dysfunction through primary care but it has not been assessed
as to how many GP practices offer this.
GP’s provision of sexual health and contraceptive services is also varied and
patchy. Despite the general understanding that all GPs offer all aspects of
level 1 and level 2 services identified by the Department of Health (see table 3
above) many do not offer some aspects. Examples of this include providing a
full screening service for STIs in asymptomatic men and women; many tend to
refer these patients onto specialist GUM clinics. Most GPs also do not provide
full partner notification for patients diagnosed with an STI other than notifying
a current partner.
Many primary care practices do not offer a full range of contraceptive methods
especially LARC methods, and very few provide an ongoing supply of
condoms; offer emergency intrauterine devices for emergency contraception
or provide same day pregnancy testing. Some practices cannot offer
contraceptive implantation removal and refer patients onto contraceptive
services. Training for primary care practitioners is also limited as capacity to
offer this by contraception services is restricted by numbers of staff qualified
to accredit them. An audit of GP provision of contraception and any necessary
training is due to launch in Oct 2008 which will enable the PCT to better
assess primary care provision of STI services and contraception.
25
Surrey currently has two practices that provide specialist sexual health
services. These are currently located in high teenage pregnancy conception
areas in Weybridge and Spelthorne. Consideration for future development of
other GPSI clinics such as these will require that existing services undergo a
full economic evaluation and that key target areas such as Woking
Runnymede and Spelthorne are chosen.
Emergency Hormonal Contraception (EHC) is primarily provided by
community contraception services, primary care and by GUM clinics if
required at the time of visiting. EHC is also offered free to under 21s through
some community pharmacies. However, coverage of all pharmacies with an
accredited pharmacist has been a challenge. Training has been ongoing and
at least 150 pharmacists have been trained altogether, but some of these
pharmacists only work part time, are locums or have moved away and some
pharmacies do not have an accredited pharmacist available for the whole of
their opening hours. A Surrey-wide PGD is being developed which will
facilitate pharmacists to move from one locality to another without losing the
ability to offer the service because of current differing PGD rules. Other
services such as Walk-in centres and A&E departments offer EHC but the
A&E department at St Peter’s Hospital does not offer emergency hormonal
contraception and will not do so on the grounds that management do not
believe that such provision should be offered in its service.
Abortion services for Surrey residents are primarily provided by services
outside of the county; through Marie Stopes International and the British
Pregnancy Advisory Service (BPAS) although there is a limited service offered
at St Peter’s Hospital. All patients in Surrey must be referred to these services
by their GP or by a doctor and nurse at GUM or contraception services.
Currently, there is no provision for self referral for an abortion and this gap can
hamper some women’s access to timely termination of pregnancy. Both Marie
Stopes and the BPAS have just been successfully commissioned to provide
LARC methods to patients using their services.
4. Contraception and contraception services
4.1 Teenage pregnancy
Teenage pregnancy is a well established and evidence based indicator of
inequality. The trend analysis table below (figures 3 and 5) show that the
South East of England and Surrey has significantly lower teenage conception
rates than other parts of England. However, in 2006 it still has more or similar
conception rates when compared to other similar counties (Table 4).
26
Teenage Pregnancy Trends in Surrey
Surrey
1997
27.6
1998
27.6
0%
1999
26.4
-4%
36.6
45.5
37.8
46.6
0%
35.9
44.8
-4%
Change in rate from baseline (%)
South East
England
Change in rate from baseline (%)
Fig. 1
Fig 3
Under 18 conception rates
2000 2001 2002 2003 2004
25.8 26.8 25.1 26.0 22.0
-7% -3% -9% -6% -20%
24.8
36.0
43.6
-6%
35.0
42.5
-9%
2005
25.3
-8%
34.4 33.1 33.3 34.1 32.9
42.7 42.2 41.6 41.3 40.4 36.2 31.9 27.6 23.3
-8% -10% -11% -11% -13% -22% -32% -41% -50%
2004 target
1998 baseline
Trajectory required to meet 2010 target
2006 2007 2008 2009 2010
25.4 23.2 21.0 18.8 16.6
-8% -16% -24% -32% -40%
2010 target
U n d e r 1 8 c o n c e p tio n r a te p e r 1 0 0 0
50
Surrey
40
England
30
South East
20
LA 2004 target
10
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Source: Teenage Pregnancy Unit, Feb 2008. (Data for 2006 are provisional)
Change in under 18 conception rate 1998-06
Surrey
South East
England
%
change
Upper
limit
-7.9
-12.9
-13.3
4.3
-9.5
-12.1
2006 conception rate with 95% confidence interval
Lower %
limit change
-18.7
-16.2
-14.5
-7.9
-12.9
-13.3
Fig. 2
Fig 4
2006
rate
Upper
limit
Lower
limit
Surrey 25.4
South East 32.9
England 41.3
Fig. 3
Fig 5
27.7
33.8
41.7
23.3
32.1
40.9
10
2004 Difference from
rate England rate
25.4 Significantly lower
32.9 Significantly lower
41.3
n/a
45
U n d e r 1 8 c o n c e p t io n s p e r 1 0 0 0
% c h a n g e in ra t e s 9 8 -0 6
(w it h 9 5 % c o n f id e n c e in t e rv a l)
40
5
0
-5
-10
-15
35
30
25
20
15
10
5
0
-20
Surrey
South East
Surrey
England
27
South East
England
Surrey: Statistical Neighbour Analysis
Table1:4:Under-18
under-18 conception
statistical
neighbours
Table
conceptiontrends
trendsbybyDCSF
DCSF
Statistical
Neighbours
Deprivation score
Under-18 conception rate
1998
2006
% difference
1998-2006
LA code
LA
43
Surrey
7.6
27.6
25.4
-7.9%
00ME
11
00MA
26
Windsor & Maidenhead
Buckinghamshire
Bracknell Forest
Hertfordshire
8.2
8.4
8.6
10.8
25.0
24.8
45.5
32.0
20.2
21.2
27.7
26.1
-19.5%
-14.8%
-39.1%
-18.4%
Figure 6: under-18 conception trends by DCSF statistical neighbours
Figure 1: Under-18 conception trends by DCSF statistical neighbours
1998 Baseline
Under-18 conception rate per 1000
50
45
40
35
Buckinghamshire
30
Windsor & Maidenhead
25
Bracknell Forest
20
Hertfordshire
Surrey
15
10
5
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Note: Data for 2006 are provisional
Figure
under-18
conception
raterate
for 2004-06
by local
authority
Figure 7:
2:Deprivation
Deprivationscore
scoreand
and
under-18
conception
for 2004-06
by local
authority
Under 18 conception rate 2004-06
100
90
80
70
Surrey
60
50
Statistical neighbours
40
R2 = 0.50
30
20
10
0
0
2
4
6
8
10
12
Index of deprivation 2004
Last update: 03.03.08
When compared with other Local Authorities of a similar nature to Surrey (Table 4
DCSF Statistical Neighbours) it is possible to see that rates have decreased at a
slower pace than other areas (Fig 6). Figure 7 shows that Surrey conception rates
correlate with deprivation which indicates the need to target resources at deprived
areas.
28
Figure 8 shows that whilst England and South East under 16 conception rates
are decreasing, Surrey’s rate remains constant. This suggests that there has
been no impact of preventative measures undertaken with this age group.
Figure 9 shows the conception rates for under 16 year olds in the different
boroughs in Surrey. Spelthorne is highlighted as having consistently higher
rates than other boroughs and Waverley has the lowest rates.
Figure 8: Under 16 teenage conception rates
Figure 9: Under 16 teenage conception rates by Borough
29
Figure 9 shows trends in under 18 conception rates by borough and highlights
that Spelthorne, Woking & Runnymede boroughs have consistently higher
teenage conception rates. Spelthorne borough has most similarities with the
national rate. These three boroughs also have 5 of the top 10 wards in Surrey
with the highest conception rates for both 2003-05 and 2002-04 data
collection periods. (See table 5) The borough of Surrey Heath shows the
single biggest increase in conception rates between 98/00 and 04/06 period
with a 21% increase change in rate, although its actual rate is still lower than
the 3 top boroughs.
Figure 10: Under 16 teenage conception rates by Borough
Source ONS
Table 5 below shows the top 19 wards in Surrey with the highest under 18
conception rates. Godalming and Ockford ward in the town of Godalming in
the South West of the county has an aggregated conception rate of nearly
twice that of the national average. It is important to note that not all areas with
high conception rates are located in densely populated areas or indeed in
areas of relative deprivation (although the two are related) and that conception
trends are not always related to service provision but may also reflect the
need for targeted sexual health promotion and / or the need for other
preventative measures such as school nursing input into sex and relationship
education
in schools and colleges and through youth services.
30
Table 5: under 18 teenage conception rate, by ward, by borough and IMD 2007.
Ranking
Ward
Borough
Rate (2003-5)
IMD (2007)
1
Godalming Central and Ockford
Waverley CD
80.5
12.68
2
Ashford North and Stanwell
South
Spelthorne CD
69.5
18.21
3
Valley
Tandridge CD
68.1
11.66
4
Sunbury Common
Spelthorne CD
66.0
16.75
5
Kingfield and Westfield
Woking CD
59.5
13.36
6
Addlestone Bourneside
Runnymede CD
56.3
11.44
Bagshot
Surrey Heath CD
55.8
6.56
8
Ruxley
Epsom and Ewell CD
53.5
13.62
9
Horley Central
Reigate and Banstead CD
52.6
13.07
9
Chertsey St Ann’s
Runnymede CD
52.6
14.78
11
Westcott
Mole Valley CD
51.0
4.99
12
Whyteleafe
Tandridge CD
50.0
8.44
13
Ash Wharf
Guildford CD
48.8
13.35
14
Stoke
Guildford CD
48.0
20.47
15
Friary and St Nicolas
Guildford CD
47.8
10.35
16
Ashford East
Spelthorne CD
47.6
10.40
16
Halliford and Sunbury West
Spelthorne CD
47.6
10.11
18
Reigate Central
Reigate and Banstead CD
47.2
6.54
19
Chertsey Meads
Runnymede CD
46.1
7.98
19
Englefield Green West
Runnymede CD
46.1
11.77
7
Source ONS 2008
31
4.2 Termination Data (Abortion)
Table 6 shows that Surrey has the highest percentage of non-NHS funded abortions (15%) within South East Coast Strategic
Health Authority region and higher rates than the national figure. It also shows that 23% of abortions in women under 25 are repeat
cases. 79% of abortions are undertaken within 9 weeks (gestation).
Table 6: Legal abortions: purchaser, gestation, Sexual Health Indicator and repeat abortions, by Primary Care Organisation, England and Local Health Board, Wales, 2007
(percentages)
Sexual Health Indicator
Gestation weeks
Purchaser (%)
Total
Percentage
NHS
abortions
of all NHS
funded
at under
funded
13+
abortions
10 weeks
abortions
(%)
Primary Care Organisation
NHS
ENGLAND
NHS
Non-
agency
NHS
0-9
10-12
Repeat
NHS
funded
Percentage of
previous
abortions in
women under
25
37
51.4
11.6
70
20
10
167,771
114,506
68.3
23.6
SOUTH EAST COAST SHA
9
81
10
76
15
9
12,539
9,314
74
23
5LQ
Brighton & Hove City
2
91
8
77
14
9
1,301
992
76
23
5P7
East Sussex Downs & Weald
4
84
12
60
28
12
787
447
57
17
5QA
Eastern & Coastal Kent
3
90
7
76
14
10
2,346
1,758
75
23
5P8
Hastings & Rother
26
70
4
73
17
10
523
376
72
17
5L3
Medway
2
90
8
77
14
10
1,018
776
76
25
5P5
Surrey
3
82
15
79
12
9
2,696
2,094
78
23
5P9
West Kent
2
88
10
82
10
8
1,943
1,582
81
27
5P6
West Sussex
38
52
10
69
21
11
1,925
1,289
67
22
Source: abortion stastics DoH 2007
32
Table 7 shows that the age-standardised abortion rate (ASR) for Surrey has gone down slightly from 16.8 in 2006 to 16.4 in 2007
Surrey has a significantly lower rate than England and since 2007 has the lowest ASR rate in the South East Coast SHA region.
Table 7. Legal abortions: rates by Primary Care Organisation: England, South East Coast SHA and Surrey by age: 2006 and 2007
Rate per
1000
women
2007
Primary Care
Organisation/
Local Health Board
ENGLAND
SOUTH EAST COAST
SHA
5P5
Surrey
Age
Total number
of abortions
Percentage
change 2006
to 2007
Total
resident
number
aged
of
15-44
abortions
ASR
Under
18
18-19
20-24
25-29
30-34
35 +
189,734
18.8
20.0
34.5
32.9
24.5
15.2
7.0
2.4%
13,926
18.2
17.1
34.4
32.2
23.4
14.9
7.3
3.7%
3,154
16.4
13.3
32.9
30.2
19.1
13.0
7.3
-0.9%
Notes: Cell value shaded if increase from previous year
2006
ENGLAND
SOUTH EAST COAST
SHA
5P5
Surrey
185,307
18.5
18.3
33.5
32.8
24.5
15.3
7.0
13,429
17.9
16.0
33.7
31.2
23.1
14.7
7.3
3,184
16.8
13.5
32.1
30.0
19.2
13.7
7.8
Source: abortion stastics DoH 2007
33
The data in Figure 11 shows that whilst Surrey has a lower rate of
conceptions than England and the South East, it has a higher percentage of
abortions. The figures also show that the rate of under 18 conception tends to
be inversely correlated with the percentage of pregnancies ending in abortion.
Rate of conceptions
0
Figure 11:
Rate of under 18
conceptions per
1,000 female
population aged 1517 and the
percentage that led
to an abortion for
top-tier Local
Authorities in the
South East 2006
Sources: Office for
National Statistics
and Teenage
Pregnancy Unit
10
20
30
40
50
60
70
England
South East
Southampton UA
Rate of
Conception
Reading UA
Medway Towns UA
Reproduced with
permission from
Health Protection
Agency & South
East Public Health
Observatory (2008)
Sexual Health in the
South East.
% leading to
abortion
Portsmouth UA
Milton Keynes UA
Brighton & Hove UA
East Sussex County
Kent County
.
Area
Slough UA
Isle of Wight UA
Hampshire County
West Sussex
Bracknell Forest UA
Oxfordshire
Surrey
West Berkshire UA
Buckinghamshire County
Windsor and Maidenhead
UA
Wokingham UA
0
10
20
30
40
50
Percentage leading to abortion
34
60
70
Table 8: under 18 teenage conception rate and the % leading to abortion, by borough
1998-00
Area of usual
residence
Number
Rate
98/00 04/06
2004-06
% leading
to abortion
Number
Rate
% leading
to abortion
% change
in rate
ENGLAND
119,036
45.0
44
118,400
41.1
47
-8.7%
1,444
26.6
56
1,435
24.2
60
-8.9%
119
18.9
53
113
15.0
57
-20.6%
93
24.0
65
85
18.1
68
-24.7%
100
29.7
63
79
20.1
62
-32.4%
104
21.5
63
115
21.2
50
-1.5%
156
25.0
39
162
23.0
56
-7.9%
163
26.1
65
156
24.6
66
-5.8%
104
21.7
54
117
26.3
68
21.0%
171
27.6
49
182
27.5
54
0.0%
150
43.6
59
105
28.7
72
-34.2%
144
28.2
56
138
28.8
59
2.3%
140
36.1
62
183
38.9
60
7.6%
Surrey
Waverley
Mole Valley
Epsom and Ewell
Tandridge
Guildford
Elmbridge
Surrey Heath
Reigate and
Banstead
Runnymede
Woking
Spelthorne
Source ONS
Table 8, as highlighted previously, shows the boroughs of Spelthorne, Woking
and Runnymede as having consistently higher rates than other boroughs. The
borough of Surrey Heath shows the single biggest increase in conception
rates with a 21% increase change in rate between 98/00 and 04/06. Of
interest is that Waverley has the lowest conception rate for 98/00 and 04/06
however the ward data for 03/5 (table 5) shows that Godalming Central and
Ockford ward in Waverley had the highest rate in Surrey for teenage
conceptions. Surrey has relatively high under 18 abortion rates with an
average of 60% of conceptions terminated in the period 2004-6 compared to
47% nationally. The borough of Runnymede recorded a rate of 72% in the
same period. However, Surrey has a significantly lower ASR termination rate
than England and a large proportion of women (79% in 2007) access a
termination before 10 weeks gestation indicating women have quick access to
terminations in Surrey.
35
4.3 Provision of contraception
It is important that people have easy
access to contraception and good
quality family planning advice. It is also
important that people have choice and
access to a full range of methods that
suit their needs. In Surrey the most
commonly used contraception is the
combined hormonal contraception,
which makes up 70% of all
contraception
prescriptions.
Long
acting reversible contraception (LARC)
methods are forms of contraception
that are of particular benefit to young
people
and
vulnerable
groups.
Currently however, it makes up only
9% of the total contraception
prescriptions supplied in Surrey
despite its availability through all
community contraceptive services and
some GP practices. GPs tend to offer
it less as an option. The percentage of
LARC prescriptions from the Community Contraceptive and Sexual Health
(CASH) Services has increased from 16% to 20% in the last 12 months (’07’08), a figure that is greater than the overall percentage of all the other
contraception prescription outlets put together. At present the most common
LARC method being offered through CASH services is the intrauterine system
(IUS) whereas the most common one offered in primary care is the injection or
depo implants. Other prescriptions for contraception include progesterone
only pill, combined hormonal contraception (such as the pill and patch), and
emergency hormonal contraception (EHC).
Figure 11: Percentage of total of prescriptions for contraception in the Surrey PCT population Dec 2006 –
Nov 2007
2%
2%
0%
7%
19%
Injection and Depot
Oral Progestogen-only
Contraceptive
Combined Hormonal Contraceptive
IUD
IUS
EHC
70%
Source: ePACT data Feb 08
36
Map 4. Provision of long acting reversible contraception (LARC) by GP practices and Surrey deprivation scores
37
Table 9. The total number of prescriptions for contraception and the rate of prescription per 1000 women
aged 15-49 years in the Surrey PCT population, by type of contraception in Dec 2006 – Nov 2007
Injection and
Depo
Oral Progestogenonly
Combined
Hormonal
Contraceptive
IUD
IUS
EHC
Rate per 1000
women 15-49yr
44.0
124.7
457.7
3.0
11.4
16.2
Total number of
prescriptions
11740
33304
122268
808
3056
4328
Source: ePACT data Feb ‘ 08
Rate of Contraception in Surrey Dec 06-Nov 07
Figure 12. Rate of prescription per 1000 women aged 15-49 years in the Surrey PCT population, by type of
contraception in Dec 2006 – Nov 2007
500
450
400
350
300
250
200
150
100
50
Source: ePACT data Feb 08
38
EHC
IUS
IUD
Combined
Hormonal
Contraceptive
Oral
Progestogenonly
Contraceptive
Injection and
Depot
-
Figure 13. Percentage of long acting reversible contraception of all contraception prescriptions from
Community Health Services
Percentage of long acting reversible contraceptives
25%
20%
15%
10%
5%
0%
England
SEC SHA
Surrey PCT 2006/7
Surrey PCT 2007/8
Source: The NHS information Centre: NHS Contraceptive Services2006/7: 2007/8 data obtained from KT31
contraceptive return completed by Surrey Community Health Service
4.4 Users’ and potential users’ views of contraceptive services
The online survey revealed that out of the
277 respondents the top two places that
people said they preferred to get their
contraception from was their GP (41%) or
a community contraception service (28%).
Pharmacies (17%) and sexual health
services (GUM) clinics (9%) were preferred
less so.
Of the 79 people who had
accessed contraception in the last 12
months, only one was male. The 78 women were predominantly aged
between 25-34 years old. The majority (97%) of all the respondents were
either extremely satisfied or satisfied with the services that they had received.
There were 5 key themes that stood out from the 40 comments offered about
people’s experience of using contraception services. However, it is not always
apparent as to which specific type of service these comments pertained.
These included positive descriptions (26 comments), which focused either on
attitude of staff or the efficiencies of the service. Positive descriptive words
used included ‘non-judgemental’, ‘smooth’, ‘easy’, ‘helpful’, ‘fast’, ‘effective’,
‘caring’ and ‘thorough’.
There were mixtures of positive and negative comments (6) but none could be
coded into specific groups, as they were all distinct. Examples include,
“It took a long time to get an appointment out of working hours but
once I was there the service was excellent”
39
“The service was quick and efficient and very caring. I would prefer not
to have to explain why I was visiting in the middle of the waiting room.”
There were 10 distinct negative comments that either focused upon difficulty
of accessing appointments outside of working hours (3), problems with access
to coils (3) or focused on the breadth of information or the type of
contraception offered e.g.
“They don’t discuss the best brand of the pill they just give me what I
want.”
“I felt that the full range of pills was not offered. I would prefer a
discussion about my lifestyle. This is needed first.” (4).
4.5 Users’ and potential users’ views about LARC Methods
The online survey revealed that 63% of people who are currently in receipt of
contraception were not offered an LARC method as an option. The results
show that GPs are less inclined to offer this compared to community
contraception services with only 31% of GPs offering it compared to 80% of
community contraception services.
The young people who participated in the focus groups had less to say about
contraception services than other topics. This may have been due to the fact
that only 5 of the 14 young people were young women and Focus Group 2
was an all male group. The key issue that was discussed about contraception
services concerned young men’s access to supplies of condoms. None of the
young men had ever been to a contraception service to get condoms nor had
they gone there to support a girlfriend with her contraception. The young men
did not appear to know where contraception services were and did not seem
to want to know. The young women (all were in Focus Group 1) had all
accessed their contraception through their GP in the first instance but had not
found this particularly satisfactory. Their biggest issue had been fear of
breaches of confidentiality, although some of the girls said that their mums
now know they are sexually active so this was no longer a concern.
Focus Group 1 discussed the relevance to men of other forms of
contraception methods apart from condoms. The general consensus was that
contraception was
“......for women and about women and doesn’t really concern us”.
This was further supported by the young men in Focus Group 2 who felt that
other forms of contraception had nothing to do with them.
40
4.6 Users’ and potential users’ views about Condoms
The online survey revealed that 82%
(227 people) of the total 277 who
answered the survey either strongly
agreed or agreed with the question that
condoms should be freely available in a
variety of non-medical settings. A total
of 265 different suggestions were put
forward, which when grouped together
elicited 43 different sites.
Youth centres were the most common suggestion with 18% (50/265).
Nightclubs, bars and pubs came second with 15.5% (41/265). Educational
establishments other than schools, such as colleges, universities and 6th form
colleges came next with 13% (35/265). Schools followed with 12.5% (33/265)
and leisure centres came 6th with 8% (21/265). Had schools been combined
with the other educational establishments listed, rather than identified as a
separate suggestion, then educational establishments would have been the
most common suggestion overall with a combined total of 26% (68/256).
Most of the young people in both focus groups had been to collect free
condoms from some other type of service other than a contraception service.
People in Focus Group 1 were very familiar with the ’Get it on’ Condom
Distribution Scheme and thought that it was a good service. They said that
more places should be part of the scheme. However, most of the boys in both
groups still tended to buy their condoms from garages or pubs. Going to a
contraception service to get condoms appeared to be culturally ‘out of bounds’
for the young men. Young men in Focus Group 2 said that they would like to
know where there are more places where you can get free condoms and
would access condoms through a condom scheme if they knew about it. Both
focus groups thought that free condoms should be made available, “just about
everywhere”, especially where young people are likely to go. Focus Group 1
was more in favour of there being an age restriction to free condoms such as
under 25 or under 21. There was no consensus as to whether condoms
should be provided free only to people on low incomes. One young woman
said, “I can’t see the system being abused by people who can afford them,
after all they’re not going to drive up to the Plantation Café in their Porsche
just to get some free condoms!”
Focus Group 2 thought that anyone should have access to them if they
needed them regardless of age or income. This was a sentiment reflected in
the online survey where 70% of people disagreed with the notion that free
condoms should only be provided to people on low incomes. Conversely, 79%
either agreed or strongly agreed that condoms should be made freely
available to anyone who wants them. Both focus groups highlighted town
centre shops as the places they thought would be most helpful to get free
condoms but this was not reflected in the suggestions provided by people
completing the online survey.
41
4.7 Recommendations for Contraception Services
A. Undertake an audit of GP sexual health and contraceptive
services and to include the ‘You are Welcome’ Quality Criteria for
young people in this.
B. Increase the promotion of LARC methods as a favourable form
of contraception and thus increase provision of LARC methods in
Primary Care. Develop the training capacity around providing
LARC methods.
C. Ensure that rural areas, particularly in the South West, which
have high teenage conception rates, have community
contraceptive provision via primary care or community
contraceptive services. This should be developed either through
Practice Based Commissioning or re-location of some existing
community contraceptive clinics.
D. Review contract with termination providers to ensure that they
are commissioned to offer LARC methods of contraception and
post termination support and that these services are promoted.
E. Lack of provision of termination services located within Surrey.
Explore with providers location of services and self-referral of
patients to services.
F. Increase condom provision in non-medical settings to anyone
who needs them e.g. not age specific but especially in places
where young people frequent, e.g. educational establishments
such as schools, colleges, 6th form colleges and universities.
G. Free pregnancy testing should be made more freely available.
H. A co-ordinated approach across Surrey to make more
contraceptive services available after working hours (particularly
on a Saturday).
I. Increase the number of pharmacies providing free EHC and
remove the upper age limit (currently 21).
J. Ward level data provides evidence for specific hot-spot areas to
develop Monday 4U drop in services for young people.
K. Notices in place in GPs and CASH clinics informing patients
that the service is confidential and non-judgemental and patients
can access a male or female doctor and / or chaperone where this
is available.
42
5. Sexually Transmitted Infections
This section looks at data related to sexually transmitted infections and makes
recommendations about the future provision and location of services.
5.1 Morbidity
Rates of sexually transmitted infections (STIs) are increasing overall in
England; this trend is also seen in the South East Coast (SEC). The most
common sexually transmitted infections in England are Chlamydia, AnoGenital Warts, Ano-Genital Herpes Simplex, Gonorrhoea and Syphilis. The
rate of these infections is also increasing with the exception of Gonorrhoea,
which shows a slight decrease at both national and local levels.
The rates of STIs in SEC are generally lower than the ones for England. In
particular, the rates of Chlamydia and Gonorrhoea in SEC are considerably
lower than the rates recorded in England. The rate of Ano-Genital Herpes
very closely reflects the rate recorded in England over the last five years.
Table 10. Rates of diagnosis of sexually transmitted disease per 100,000 populations 2003-2007 in England.
Source: HPA
2003
2004
2005
2006
2007
Chlamydia
161.5
175.0
181.7
187.8
201.3
Gonorrhoea
41.9
37.3
32.0
31.2
30.9
Syphilis
2.8
3.8
4.5
4.4
4.4
Herpes
32.3
31.9
32.9
36.0
43.0
Warts
128.6
133.8
134.9
138.0
148.3
Figure14. Rate of diagnosis of sexually transmitted disease per 100,000 populations 2003-2007 in England.
225
Rates of STI diagnosis in England
200
175
150
Chlamydia
Gonorrhoea
Syphilis
Herpes
Warts
125
100
75
50
25
0
2003
2004
2005
Year
Source: HPA
43
2006
2007
Table11. Rates of diagnosis of sexually transmitted disease per 100,000 population 2003-2007 in South East
Coast. Source: HPA
2003
2004
2005
2006
2007
Chlamydia
100.8
130.9
125.3
137.8
152.0
Gonorrhoea
20.1
22.0
18.5
19.1
17.9
Syphilis
2.3
3.3
2.2
2.4
2.7
Herpes
30.7
31.9
29.1
32.0
40.4
Warts
114.6
123.2
123.6
127.5
136.9
Figure15. Rate of diagnosis of sexually transmitted disease per 100,000 population 2003-2007 in South East
Coast Strategic Health Authority. Source HPA 2008
Rates of STI Diagnosis in the South East Coast
160.0
140.0
120.0
100.0
Chlamydia
Gonorrhoea
Syphilis
Herpes
Warts
80.0
60.0
40.0
20.0
0.0
2003
2004
2005
2006
2007
Year
Due to the way data is currently collected in Surrey, we are unable to
accurately calculate Surrey prevalence data. To provide an indication of the
various trends in STI rates, we have compared the percentage rate of change
each year from 2003 to 2007 in Surrey and in the South East Coast with
diagnosis of total numbers of STIs.
The percentage increase in diagnosed cases of Syphilis is large in Surrey
(52% from 2006 to 2007), but the number of cases is relatively small (32
cases in 2007). The rates of Chlamydia in Surrey have gone up at a slightly
higher rate than the South East Coast for the last two years (2005/2006 –
21%, to 2006/2007 - 15% in Surrey compared with 11% and 10% in South
East Coast). The trends for Gonorrhoea show a decrease in 2006 to 2007 in
both Surrey and the South East Coast. The rate of Ano-Genitial Herpes is
increasing by about 25% in both the South East Coast and Surrey in 2006 to
2007. The rate of Ano-Genital Warts has been relatively stable for the last 5
years in both Surrey and the South East Coast.
44
Table12. Total number of diagnosis of sexually transmitted disease 2003-2007 in South East Coast Strategic
Health Authority. Source: HPA
2003
2004
2005
2006
2007
Chlamydia
4,205
5,483
5,280
5,855
6,459
Gonorrhoea
838
923
780
810
762
Syphilis
98
138
91
104
113
Herpes
1,280
1,335
1,227
1,361
1,717
Warts
4,778
5,158
5,207
5,418
5,816
Figure16. Total number of diagnosis of sexually transmitted disease 2003-2007 in South East Coast
Strategic Health Authority. Source: HPA
7,000
Total Diagnosis of STIs in the
South East Coast
6,000
5,000
Chlamydia
Gonorrhoea
Syphilis
Herpes
Warts
4,000
3,000
2,000
1,000
0
2003
2004
2005
2006
2007
Year
Table13. Total Number of diagnosis of sexually transmitted diseases 2003-2007 in Surrey PCT Source: HPA
2003
2004
2005
2006
2007
Chlamydia
1095
1326
1312
1588
1830
Gonorrhoea
190
173
154
175
156
Syphilis
18
29
13
21
32
Herpes
415
371
361
454
566
Warts
1297
1351
1310
1360
1497
45
Figure 17- Total number of diagnosis of sexually transmitted diseases 2003-2007 in Surrey PCT Source: HPA
2000
1800
Total diagnosis of STIs in Surrey
1600
1400
Syphilis
Gonorrhoea
Herpes
Warts
Chlamydia
1200
1000
800
600
400
200
0
2003
2004
2005
2006
2007
Year
Table14. Percentage yearly change in number of diagnosis of STIs in the South East Coast and Surrey PCT
from 2003-2007 Source: HPA
South East
Coast
Surrey PCT
2003/4
2004/5
2005/6
2006/7
Chlamydia
30
-4
11
10
Gonorrhoea
10
-15
4
-6
Syphilis
41
-34
14
9
Herpes
4
-8
11
26
Warts
8
1
4
7
Chlamydia
21
-1
21
15
Gonorrhoea
-8
10
14
-11
Syphilis
61
-55
62
52
Herpes
-11
-3
26
25
Warts
4
-3
4
10
5.2 Analysis of STI cases
Analysis of all diagnoses of sexually transmitted infections, including the five
most common infections, show that the percentage of cases seen in men who
have sex with men (MSM) is higher in England than it is for Surrey. The
overall percentage of STI infection for women patients is lower in Surrey
compared to that of women in England in general.
46
Surrey
England
Table 15 - Total number of STI diagnosis by persons affected 2003-2007 in England and Surrey
2003
2004
2005
2006
2007
Male non MSM
143,562
149,776
150,211
152,309
165,302
Male MSM
18,030
18,521
20,509
21,835
21,548
Female
184,576
194,992
197,538
201,699
211,140
Total
346,168
363,289
368,258
375,843
397,990
Male non MSM
4768
5124
5483
5660
5626
Male MSM
308
314
277
206
224
Female
4327
4984
5167
5280
5327
Total
9403
10422
10927
11146
11177
Source: HPA
Figure 18 – Percentage of STI diagnosis by persons affected 2003-2007 in England and Surrey
100%
90%
Percentage of STI diagnosis
80%
70%
60%
Female
Male MSM
Male non MSM
50%
40%
30%
20%
10%
0%
2003
2004
2005
2006
2007
Surrey
2003
2004
2005
England
Source: HPA
47
2006
2007
5.3 Chlamydia Screening
Surrey PCT only started its Chlamydia Screening Programme in 2006. This
formed Phase 3 of the national roll out of the scheme and the start of a 5-year
programme for Surrey. This late start is reflected by low rates of screening in
the first instance. Currently, screening occurs through opportunistic selfreferral. In 2007, Surrey screened 2.2% of the target population and there is
some way to go to reach the Department of Health’s target to screen 17% of
all 15-24 year olds (20,141 screens) by the end of March 2009. Between 1st
April 2007 and 31st March 2008, the overall percentage of 15-24 yr olds
screened in England was only 4.9%.
The Surrey Chlamydia Screening
Programme aims to increase the
numbers of screenings over the
coming years through a range of
innovative
interventions
which
include sending out personal
invites to all 19-24yr olds registered
with a Surrey GP to come forward
for screening and making testing
kits
available
pharmacies.
in
community
Analysis of screening figures reveals that the positivity rate of young people
being screened for Chlamydia in Surrey is 6.3%. This is lower than the rest of
England, which has a positivity rate of 9%. The low rate in Surrey may be due
to the nature of the population coming forward for screening or may simply
reflect a low prevalence in the area. This has yet to be determined. In Surrey,
diagnosis of Chlamydia is highest in 20-24 year olds. It is also diagnosed
more commonly in young women under 20 years old than it is in men of the
same age. Only when screening numbers increase is it possible to provide an
accurate indication of prevalence rates and where and with which population
groups prevalence is highest in Surrey.
Figure 19 - Percentage of 15 to 24 year olds screened for Chlamydia April 2007 to March 2008 by area
Percentage of 15-24 year olds screened
10
9
8
7
6
5
4
3
2
1
0
Brighton
and Hove
City
Eastern
and
Coastal
Kent
Medway
East
Sussex
Downs
and
Weald
Hastings
and
Rother
West
Kent
48
West
Sussex
Surrey
South
East
Coast
England
Table 16. Percentage of positive results for 15 to 24 year olds screened for Chlamydia 2008 in Surrey
Month
Positive % For Month
Total For Month
January
8.46%
390
February
6.53%
306
March
5.61%
641
April
5.36%
429
May
5.84%
513
June
5.74%
331
July
9.74%
431
Source: Surrey Chlamydia Screening Programme 2008
Figure 20. Percentage of positive results for 15 to 24 year olds screened for Chlamydia 2008 in Surrey
10%
Percentage of Chlamydia tests positive in Surrey
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
January
February
March
April
May
June
July
2008
Source: Surrey Chlamydia Screening Programme
5.4 HIV infection in Surrey
The total number of diagnosed HIV infected people in Surrey has been
increasing over the last 5 years. However, the rate in Surrey is relatively low
compared to other areas in South East Coast region. The steadily increasing
rate of new HIV diagnoses for Surrey and Sussex follows national trends. The
relatively large numbers of HIV positive black Africans in Surrey appear to
directly reflect the global pandemic where the majority have contracted the
virus through heterosexual sexual contact. A significant proportion of Surrey’s
49
black Africans have contracted it whilst living abroad or visiting their countries
of origin. In 2006, just under half of the people in the UK, who contracted HIV
through heterosexual sex, were black African women. The proportion of black
Africans with HIV living in Surrey is much higher than the rest of the South
East Coast.
The majority of white Surrey residents living with HIV are men who have
contracted the virus through having sex with other men. The period between
2002 and 2006 saw the largest increase in numbers of people living with HIV
in Surrey and who are accessing HIV treatment centres. Other routes of
transmission include injecting drug use, blood or blood product transfusion
and mother to child transmission; the percentage of which is extremely low
compared to sexual transmission.
Table 17. Total number of patients with HIV in Surrey in by year
Year
Total
2002
369
2003
452
2004
493
2005
558
2006
585
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
Figure 21 – Rate of new diagnosis of HIV in the South East Region and England 1996-2006 in adults per
100,000 people
Source: HPA & South East Public Health Observatory, 2008 Sexual Health in the South East,
reproduced by kind permission
50
Map 5 – Prevalence of people living with HIV within the South East per 100,000 population by PCT in 2006
Source: HPA & South East Public Health Observatory, 2008 Sexual Health in the South East, reproduced by kind
permission
Figure 22. Total number of Diagnosed HIV infected patients in 2006 by Gender and Age in South East Coast
patients
Total Number of HIV diagnosed individuals living in the
South East Coast in 2006
1000
900
800
700
600
Male
Female
500
400
300
200
100
0
<15
16-24
25-34
35-44
Age
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
51
45-54
55+
Figure 23 – Total number of Diagnosed HIV infected patients in 2006 by Gender and Age in Surrey PCT
patients
Total number of HIV diagnosed individuals in
Surrey in 2006
135
120
105
90
75
Male
Female
60
45
30
15
0
<15
16-24
25-34
35-44
45-54
55+
Age
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
Percentage of people with HIV by Ethnicity in the South
East Coast
Figure 24 – Percentage of Diagnosed HIV infected patients by Ethnicity in the South East Coast from 2002 to
2006
100%
90%
80%
70%
60%
other/Not known
Black-African
White
50%
40%
30%
20%
10%
0%
2002
2003
2004
Year
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
52
2005
2006
Figure 25 – Percentage of Diagnosed HIV infected patients by Ethnicity in Surrey from 2002 to 2006
Percentage of Diagnosed HIV infected individuals in
Surrey
100%
90%
80%
70%
60%
Other/Not known
Black-African
White
50%
40%
30%
20%
10%
0%
2002
2003
2004
2005
2006
Year
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
Figure 26 – Percentage of Diagnosed HIV infected patients by likely mode of transmission the South East
Coast 2002-2006
Percentage of People in South East Coast with HIV by
likely mode of transmission
100%
90%
80%
70%
60%
Other/Not known
Sex between men & women
Sex between men
50%
40%
30%
20%
10%
0%
2002
2003
2004
Year
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
53
2005
2006
Figure 27 – Percentage of diagnosed HIV infected patients by likely mode of transmission in Surrey 20022006
Total number of people in surrey with HIV by likely
mode of transmission
100%
90%
80%
70%
60%
Other/not known
Sex between men and women
Sex between men
50%
40%
30%
20%
10%
0%
2002
2003
2004
2005
2006
Year
Source: HPA survey of Prevalent HIV Infections Data (SOPHID)
A separate health needs assessment is being undertaken jointly with Surrey
County Council. This will focus on the HIV related social care support needs
of people living with HIV. The report on this will be published early in 2009.
The health needs of people living with HIV also require assessment. GUM
clinics, however regularly evaluate their services and address issues as they
arise.
5.5 Genito-Urinary Medicine (GUM) Clinic Activity
Our busiest GUM Clinics are St Peter’s Hospital in Chertsey and Farnham Rd
Hospital in Guildford, followed by Frimley Park Hospital, East Surrey Hospital
and Leatherhead Hospital. This difference in demand is created in part by the
varying restrictive opening hours that each clinic is able to operate and in part
by the size of the population in the area. The Leatherhead clinic is the only
clinic with available physical capacity for future expansion. East Surrey clinic
is currently relocating to new premises, which provides an opportunity for
piloting a one-stop-shop model of sexual health and contraceptive service.
54
Table18. Surrey GUM Workload in 2007
East
Surrey
Hospital
Farnham rd
Hospital
Frimley Park
Hospital
Leatherhead
Hospital
St Peters
Hospital
Total for
Surrey
New STI
Diagnoses
848
2094
1467
542
1546
6497
Other STI
Diagnoses
460
1444
977
433
1590
4904
Other diagnoses in
GUM
1115
2268
913
540
3189
8025
Services provided
6460
11772
8066
3466
11917
41681
Data provided by HPA (2008)
GUM Workload Code Groups
Other STI Diagnoses
New STI Diagnoses
Chlamydial infection (uncomplicated and complicated)
Gonorrhoea (uncomplicated and complicated)
Early latent, congenital and other acquired syphilis
Infectious syphilis
Recurrent genital Herpes simplex
Genital Herpes simplex (first attack)
Recurrent and re-registered genital warts
Genital warts (first attack)
Subsequent HIV presentations (including AIDS)
New HIV diagnosis
Ophthalmia neonatorum (chamydial or gonococcal)
Epidemiological treatment of suspected STIs
(syphilis, chlamydia, gonorrhoea, non-specific
genital infection)
Non-specific genital infection (uncomplicated and
complicated)
Chancroid/lymphogranuloma venerum (LGV)/Donovanosis
Molluscum contagiosum
Trichomoniasis
Scabies
Pediculus pubis
Other diagnoses made at GUM clinics
Services provided
Viral hepatitis B
HIV antibody test
Viral hepatitis C
Sexual health screen
Vaginosis and balanitis (including epidemiological treatment)
Hepatitis B vaccination
Anogenital candidiasis (including epidemiological treatment)
Contraception (excluding condom provision)
Urinary tract infection
Other episode not requiring treatment
Cervical abnormalities
Other conditions requiring treatment at a GUM clinic
55
5.6 GUM Clinic Access
Table 19 shows how access to Genito-urinary medicine (GUM) services has improved over the last two years. In June 2008, 100%
of patients calling for an appointment in Surrey were offered an appointment within 48 hrs of first contacting the service. Further
work is underway to increase the percentage of patients seen within 48 hrs.
Table19. Percentage of patients who were offered an appointment and seen at GUM clinics in Surrey within 48 hours
Responsible organisation
GUM Clinic
Line
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
ASHFORD & ST PETER’S NHS
TRUST
St Peter’s
Hospital
% offered
96%
94%
96%
96%
97%
98%
100%
100%
100%
% seen
70%
72%
72%
71%
71%
77%
71%
81%
70%
FRIMLEY PARK HOSPITAL NHS
FOUNDATION TRUST
Frimley Park
Hospital
% offered
100%
100%
100%
100%
100%
100%
100%
100%
100%
% seen
85%
84%
79%
89%
83%
83%
87%
88%
83%
East Surrey
Hospital
% offered
82%
78%
79%
85%
100%
100%
100%
100%
100%
% seen
78%
75%
77%
79%
79%
76%
73%
84%
81%
Farnham Road
Hospital
% offered
88%
93%
92%
97%
99%
100%
100%
100%
100%
% seen
64%
73%
74%
83%
83%
86%
82%
83%
80%
Leatherhead
Hospital
% offered
82%
92%
90%
89%
98%
100%
100%
100%
100%
% seen
69%
72%
77%
74%
73%
83%
75%
66%
78%
% offered
84%
83%
86%
95%
96%
99%
98%
99%
99%
% seen
75%
74%
78%
83%
83%
85%
86%
88%
87%
% offered
91%
92%
92%
96%
97%
99%
98%
99%
% seen
78%
80%
82%
84%
84%
86%
84%
86%
SURREY PCT
SEC GUM Clinic
Total
England
56
5.7 Sexually Transmitted Infections (STIs): users’ and potential users’
views
The online survey revealed that
most people would prefer to get a
check-up for STIs from a GUM
clinic with 40% opting for this and
38% opting for their GP. 19% opted
for a service that was referred to as
a community contraceptive and
sexual health clinic. Only 43 people
who completed the survey (16%)
had asked for a sexual health
check up in the last 12 months (10
men and 33 women). The vast
majority (77%) went to a GUM
clinic to receive this and 11% went
to a GP. The biggest single group
of people (15) who attended for a
check up were aged 25-34 and 12
people were aged 16-24 years.
The vast majority (95.5%) were
either extremely satisfied or
satisfied by their experience of
attending such services.
A total of 25 people made comments on their experience of using a sexual
health service, the majority of which were positive comments. It was not
possible to ascertain whether people were referring to their experience at a
GUM clinic or their GP. Comments tended to focus upon the attitudes of the
staff and the overall experience they had received. Words such as: friendly,
‘helpful’, ‘non-judgemental’, ‘polite’ and ‘supportive’ occurred frequently. One
person said,
“I was very scared and very upset. I was treated with compassion and
given facts. I could not recommend them enough for the help they
provided at this very distressing time.” Another said, “Excellent, put me
at ease, very professional and friendly.”
All the participants in both focus groups appeared uncomfortable about
discussing sexually transmitted infections and although the word stigma was
not used by anyone, there was a general negative association with having a
check up. The act of doing so was seen as something ‘bad’. All the
participants said that they’d only want to be seen by a female doctor, the
young men in Focus Group 2 were slightly uncomfortable by the possibility of
being examined by a male doctor or nurse. It could be speculated that this
reflected a homophobic stance but it was not possible to explore this aspect
further. Nevertheless, this issue was a big issue for them. However, none of
the young men in Focus Group 2 had ever been for a sexual health check up
even though most were aware of the existence of clinics specifically for this.
They didn’t know what they were called. Two of the young men in Focus
Group 1 knew of the GUM clinic at Farnham Road Hospital but neither had
57
been to it. However, one young man from Focus Group 1 referred to having
an STI as “…having a problem” and he went on to say that, “If things were
really bad and I was in pain, I‘d go wherever.”
It seems that the promotion and publicity of sexual health services to young
people should consider dispelling myths about access and emphasising
patient choices such as being able to access a male or female doctor.
5.8 Sexual Health Services (GUM): Recommendations
A. As with contraceptive services, audit GP sexual health services to
find out what provision of STI screening and management is currently
being provided.
B. Increase level 1 and 2 services in the community either through
Practice Based Commissioning or Community Contraceptive and
Sexual Health Services development such as Outreach GUM services
similar to the ones in Horley and Addlestone.
C. Deliver more Sexually Transmitted Infections Foundation (STIF)
courses to promote STI screening and treatment in non-GUM settings.
D. To ensure all GUM clinics are providing results of all tests regardless
of whether they are positive or negative and do not operate a ‘no news
is a good news’ policy.
E. Ensure notices are in place in GUM clinics informing patients that the
service is confidential and non-judgemental and that patients can
access a male or female doctor and / or chaperone if they choose.
F. Sexual health services to be promoted and publicised better and their
processes to be made more explicit in publicity materials. This could be
achieved by further development and promotion of the current sexual
health website.
G. To help provide the best possible choice for patients, co-ordinate
across Surrey GUM clinics to increase access to services e.g. pilot
making more sessions available after working hours and / or open on a
Saturday morning.
H. Continue to develop innovative ways to reach the target population
for Chlamydia screening
I. Assess the social care needs for HIV positive people living in Surrey
J Ensure that GUM clinics meet the DH You’re Welcome quality criteria
for young people within 12 months
58
6. Other Sexual Health Issues
6.1 Psychosexual Problems
There is a distinct lack of psychosexual services in Surrey. Most are provided
by Relate which offers couples therapy for a sliding scale fee. There are a few
isolated NHS services. In addition, the provision provided by Surrey and
Borders Partnership Trust is being de-commissioned. A separate review is
needed to address this issue.
6.2. Users’ and potential users’ views about sexual problems
The online survey revealed that GP practices (42%), GUM clinics (30%) and
community contraceptive and sexual health services (22%) were the top three
places that people would go to if they needed face-to-face treatment for a
sexual problem. However, it is not clear from these results as to whether
people know of other places where they might be able to get such services
from. There were 8 ‘other’ suggestions offered of which two suggested having
a dedicated specialist service and two suggested having a service at a youth
centre.
Both Focus Groups identified their GP as someone who they would go to if
they had a sexual problem but both groups thought that having a specialist
service for this would make it easier for people to access help for such a
problem. Focus Group 2 was more concerned about the embarrassment
factors of admitting to having a sexual problem and thought that going to a GP
would be too embarrassing especially if the practitioner was male. Focus
Group 1 thought that their GP would be more confidential but also felt that it
would be too embarrassing to discuss with their GP. Both groups said that
they would prefer to access treatments such as Viagra on the Internet,
especially if it meant avoiding going to their GP.
“Imagine how embarrassing it would be to have to see a bloke. It just
wouldn’t be right. I ‘d rather look on the internet.”
None of the participants in either group said that they had ever been seen by
a professional about a sexual problem but understood that it could affect
anyone at any time. They concurred that a specialist service that was
separate from their GP’s surgery would make it easier to go there and this
would help with the embarrassment factor as well as confidentiality. Neither
group could suggest a place where they would go but one group thought that
a local telephone helpline would help some people to talk about their sexual
problem and it would help to keep such discussions anonymous and less
embarrassing.
Only 15 people who completed the online survey said that they had had
therapy or treatment for a sexual problem in the last 12 months, 4 of these
were male and 11 were women. The age range for men was evenly spread
but over half of women who had accessed treatment were aged 25-34 (6).
59
There were more people who answered the question as to where people had
accessed treatment or therapy (33) than had admitted to having had a sexual
problem (15). This might indicate that the term ‘sexual problem’ was
misunderstood to mean more than a psychosexual problem and could include
physical genital conditions. A total of 14 of the 33 who had accessed
treatment had gone to GUM clinics, 5 to their GP, 13 had gone to ‘other’
places and one had gone to a private sex therapy service, but none had said
specifically where they had gone. Of the 34 people who answered the
satisfaction question 26 were either extremely satisfied or satisfied with the
services they received.
6.3 Sexual health promotion
There is a range of multi-agency
services involved in sexual health
promotion in Surrey. This ranges
from work with young people in
schools to specific interventions
with sex workers and gay men.
Most of the prevention work with
young people is co-ordinated
through the Surrey Teenage
Pregnancy Strategy. In addition to
young people there are other
groups that are disproportionately
affected by sexual ill health or are
particularly vulnerable to sexual
exploitation,
abuse
or
have
difficulty in accessing services.
The key specific groups in Surrey
are explored next.
6.4 People from black and minority ethnic (BME) communities
According to the 2001 National Sexual Health Strategy people from BME
communities are disproportionately affected by STIs and HIV. It has not been
determined here whether this is the case in Surrey as prevalence rates for
STIs are unavailable. It has, however, been proven that this is the case with
HIV infection, but only affecting those BME populations from Sub-Saharan
Africa. Maybury and Sheerwater wards in the borough of Woking have the
highest ethnic population in one geographical area and can be viewed as
being an identifiable community, mainly South Asian, but it is also an area that
has extremely low teenage conception rates. This bucks against national
trends. The African populations living in Surrey are geographically
concentrated in areas that have good transport links into London such as
Woking, Guildford, Staines, Epsom and Redhill. The provision of STI
prevalence data will help determine some aspects of need of BME groups and
this data should be available in 2009.
60
6.5 Sex workers in Surrey
Sex workers carry a higher risk of contracting STIs than the general
population. The people involved in sex work often face greater challenges with
practicing safer sexual practices and safer substance use, have limited
access to appropriate services and are more likely to experience violence and
exploitation. In Surrey, there is no “street scene” where sex workers are on
the street and as such, sex work remains largely hidden from public view.
Most sex work occurs in private dwellings, mainly flats or is conducted by sex
workers going out to visit clients in hotels or other private dwellings. Surrey
does not have a Vice Unit but this does not suggest sex work and trafficking is
not an issue in Surrey.
The Surrey Harm Reduction Outreach Team provides an outreach service to
men and women in the sex industry. They provide safer sex advice, support,
safer sex supplies and a point of contact for screening for some STIs and
blood borne viruses. During the period 1/04/07 to 31/03/08 the Outreach
Service made a total of 400 visits to sex workers. These visits take place in a
variety of settings such as working flats or brothels, cafes or other public
places, in workers’ cars, the ‘Xchange’ needle exchange in Woking, an escort
agency base, sexual health clinics or other health service venues, sex
workers’ own homes, hotels, at social events, lorry parks/truck stops and
‘dogging’ sites. The transient nature of many of the women working in flats
can make repeat contacts problematic. Engaging women to access services
is made more difficult by the legality of prostitution, which can lead to women
being marginalised and vulnerable. Sex workers’ specific needs include easy,
non-judgemental access to sexual health and contraceptive services, testing
and screening for STIs, vaccination for hepatitis B, access to a range of
condoms, lubricants and sexual health advice and education. The Outreach
Team is developing projects, services and resources to meet the needs of sex
working clients. This includes projects with Downview and Bronzefield prisons.
6.6 People with a Learning Disability and Mental Health Problems
Young people and adults with learning disabilities or mental health problems
are not represented in Surrey’s pregnancy, abortion or STI rates, as data is
not specifically collected on this. However, it is recognised that these groups
of people have the right to enjoy positive sexual health but can be more
vulnerable to sexual exploitation and abuse. They also require specific
support to access protection, prevention, treatment and care.
Surrey PCT is currently working with Surrey and Borders Partnership Trust
(SABT), which has a remit to provide support and care for people with
learning disabilities and mental health problems, develop an overarching
public health strategy that contains specific reference to sexual health. Their
emerging public health strategy has identified the following key points for
specific attention:
61
•
•
•
•
•
•
Ensure senior level representation on the Surrey-wide Sexual Health
Strategy Group.
Ensure that staff are appropriately trained to signpost clients to
appropriate mainstream services; understand the law regarding child
protection issues with specific reference to sexually active U18 year
olds and vulnerable adults and understand infection control and the
“universal precautions” agenda
Ensure service users are supported in accessing STI diagnoses and
treatment provided by sexual health and contraception services
Support ‘high risk’ users to access dedicated information, advice and
support services.
Improve links with primary care and establish clear referral pathways.
Ensure that all young people receiving a service from the Trust have
access to appropriate education, advice, information and services on
matters relating to sexual health.
6.7 The Prison Population
The operational capacity of a prison is the total number of prisoners that an
establishment can hold taking into account control, security and the proper
operation of the planned regime. The sexual health needs of Surrey prisoners
have not been fully assessed though it is recognised that this particular
population group is large and many will be vulnerable and have specific
needs.
Table 19 : Profile of Surrey Prisons
Surrey Prisons
Gender
Operational capacity
(number of inmates)
High Down, Banstead
Male
747
Downview, Banstead
Female
358
Bronzefield, Ashford
Female
450
Coldingley, Woking
Male
390
Send, Woking
Female
218
Source: HM Prison Service (www.hmps.gov.uk), 2007
Issues around HIV and Hepatitis C infection and testing are commonplace for
both men and women in Surrey prisons. Women’s contraception needs
remain an issue for them despite incarceration, as does screening for
Chlamydia and other STIs, managing pelvic inflammatory disease and
pregnancies.
62
There are 5 prisons in Surrey; 3 are for women (Send near Guildford,
Bronzfield in Ashford near Staines and Downview in Banstead), and 2 are for
men (High Down in Banstead and Coldingley near Woking). The sexual health
needs of prisoners at Highdown are managed by a GUM Consultant from the
Blanche Heriot Unit at St Peter’s Hospital who visits Highdown on a weekly
basis for 3 hours and attends Coldingley on a monthly basis for 2 hours. This
same consultant also provides an ad-hoc service to women at Downview, but
women from there normally attend the clinic at Blanche Heriot with a prior
arranged appointment. Through the ‘GUM outreach’ service prisoners have
access to a full sexual health service including screening and testing for
Chlamydia and Gonorrhoea and a full range of tests for blood borne viruses.
HIV positive prisoners are also supported on site. Sexual Health outreach
services at Send are currently suspended. Women prisoners at Bronzefield
currently access sexual health services by attending the Blanche Heriot GUM
Clinic by prior arranged appointments. At present the Consultant from the
Blanche Heriot does not have Nursing or Health Adviser support.
6.8 Men Who Have Sex with Men (MSM)
Across the UK 1 in 20 gay and bisexual men are living with HIV. It is
estimated that around one in ten live in London15. The Department of Health16
states that, “Sex between men remains the major transmission route for HIV
in this country”. It is for this reason that HIV prevention work both nationally
and locally is targeted at gay men as they are the most prevalent group
affected by HIV.
In recent times the culture of socialising with other gay men or with men who
have sex with men (MSM) within Surrey has changed due to the fact that
there is no permanent gay only venue locally. However, there are various
social groups that exist and meet regularly around the county. There are four
lesbian, gay, bisexual and transgender (LGBT) youth groups that operate and
these are provided by either Connexions or Surrey Youth Development
Service. The Surrey PCT Health Promotion Outreach Worker for gay men has
regular input into these groups.
Some of the hardest to reach men in Surrey are those that use Public Sex
Environments (PSEs). Some of the men who use these sites do not identify as
being gay or bisexual but they do, nevertheless, have sex with other men. In
Surrey, there are two of the most well known PSE sites located in the South
East of England. Surrey residents regularly use these as do people from
further afield. Regular Outreach sessions are carried out at these sites and
more intermittent sessions carried out at those less popular with users. At
present the Terence Higgins Trust provides the health promoting sessions in
the East of the county and the PCT Development Worker covers the West.
There is some overlap at a key site just outside Guildford but this is a huge
site and well used by the target group.
Many barriers still remain to carrying out HIV prevention work with
homosexually active men. Central to this is the social taboo of homosexuality,
63
discrimination against gay men and those diagnosed with HIV.17 With this in
mind, prevention work centres on breaking down structural barriers that gay
and bisexual men face in Surrey. The Development Worker also works closely
with Surrey Police around issues of ‘hate crime’ and helps to support the
breaking down of barriers that exist between the gay population and the
Police. Interventions include training on lesbian, gay and bisexual awareness,
male rape and same sex domestic abuse.
6.9 Users’ and potential users’ views on ‘other’ sexual health issues
The online survey did not ask a specific question about sexual health
promotion but issues about it were highlighted when people were asked to
make further general comments at the end of the survey. From the 59
comments that were put forward 12 made specific references to the need for
contraception and sexual health services to be better promoted. Some
examples of what people said include:
“People are sometimes unaware and unsure of what (services) they
can get and from where, so they leave it”,
“I did not know about GUM clinics and I do not know where they are.”
“They aren’t advertised very effectively.”
On a slightly different theme one person suggested that we call sexual health
services “good sexual health” so that there was greater emphasis placed upon
“good health rather than disease.” This same theme was brought up by
various people providing qualitative responses and by the two Focus Groups
but in different ways. Some touched on the prevailing presence of stigma
surrounding sexual health and STIs, others raised concerns about accessing
services which are clearly marked as such. On the one hand young people
said that they would find it too embarrassing to go to their GP to discuss
sexual problems but on the other hand said that they wanted services to be
explicitly labelled as sexual health services to help reduce confusion and to
help reduce the general feeling of embarrassment. It would seem that young
people are arguing for positive sexual health promotion aimed at destigmatising sexual health.
Conversely, 77% (175 women and 39 men) of people said no to the question
as to whether they find it difficult to raise personal sexual health concerns with
their doctor or nurse indicating that embarrassment may not be such a
problem and that barriers to this have begun to be broken down. The
proportion of men and women who said they do find it difficult was similar with
22% and 23% respectively. This seems to indicate that there is no general
bias amongst the sexes as to who finds it more difficult.
A total of 63 people said they do find it difficult to raise sexual health issues
with their Doctor or nurse. Only 53 provided suggestions as to what might
help them to overcome this. The attitude of staff was the single most common
issue / barrier identified and was highlighted by 13 people. Several specifically
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mentioned the need for staff to be non-judgemental, offer unbiased
information and advice, to be friendly, approachable and not to appear to be
in a hurry or to be rushed (4). A total of 12 people said that it would be easier
for them to raise their sexual health issues if there was a dedicated specialist
sexual health practitioner at the practice, someone who was not their usual
practitioner and preferably if this was someone who was trained and qualified
in the field of sexual health.
A total of 8 people highlighted the gender of the staff member as being
important and there were several requests for better access to a female
doctor but it was not possible to ascertain from the data whether this was in
primary care or in GUM services. This was also highlighted as an issue for the
young men in Focus Group 2 who emphasised that having a female doctor or
nurse was “essential” if they were to bring up sexual health issues at their GP
practice or sexual health clinic.
A total of 10 people identified the fear of their confidentiality being broken as a
key barrier for them and 7 of these suggested having an anonymous service
so their regular GP would not be informed. Other solutions put forward for
remaining anonymous included: having special confessional booths, being
asked questions through survey tick boxes and using a computer to answer
embarrassing questions. A further three people suggested that the doctor or
nurse should be more proactive with patients and bring up the subject first.
The online survey did ask where people would most likely look for information
about sexual health services in Surrey. Of all the responses 33% highlighted
the Internet (204/610) as the most likely place, 28% said they’d ask their GP
or Practice Nurse, 10% said they’d ask their friends and 9% said they would
look in a telephone directory.
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6.10 Recommendations about other sexual health services
and sexual health promotion
a. To undertake a separate needs assessment into sexual problems and
the provision of psychosexual counselling and treatment with a view to
extending service provision across the county.
b. Maintain an approach of targeting sexual health promotion at higher risk
or vulnerable groups such as gay men and sex workers in Surrey and to
further develop peer initiatives.
c. Ensure that any future prison health needs assessment takes sexual
health into account and considers the services required to provide
appropriate treatment and care, sexual health education for both staff and
prisoners and provide preventative measures such as access to condoms
on leaving prison.
d. Continue to work in partnership with the Surrey and Borders Partnership
Trust and to support them to undertake their own needs assessment to
help ensure that the sexual health needs of people with learning disabilities
and mental health problems are met and that service users have good
access to mainstream services.
e. Explore the feasibility of a local sexual health telephone helpline to
increase access to information, advice and referral for sexual problems,
including psychosexual problems, relationship problems and where queries
or concerns about HIV and STIs can be discussed.
f. Further develop and fully promote the current Surrey sexual health
services website www.cybershs.nhs.uk. Consider how this website can be
used to deliver creative ways in which patients, especially young people,
can ask embarrassing questions. Also utilise social marketing approaches
and ensure young people are involved in this process
g. The website to be linked to the Surrey County Council and any district
council websites
h. Consider ways in which people, especially young people, can approach
GP services with sexual health queries and promote the adoption of the
DH You’re Welcome quality criteria.
I The ‘Monday 4U’ model of community CASH services should be
expanded.
J. A review undertaken into the provision of sexual health promotion
services.
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7. Access to future contraceptive and sexual health
services
7.1 Access to one-stop-shops
The online survey asked participants to comment as to whether they thought it
would be a good idea or not to combine contraception and sexual health
services. The vast majority (83%) of both men and women concurred that it
would be. Qualitative data gathered on why people thought so revealed 5 key
themes. The most common suggestion, 38%, thought that it would make
things easy and more convenient (21/56), 25% thought that it might help to
reduce stigma (14/56), 12.5% thought that the two services are logically
related and 11% suggested that combining the two would increase choice and
make both services better (6/56). 9% thought that it would be more cost
effective (5/56).
Reducing stigma was seen as a potential positive outcome of combining
sexual health and contraception services by 25% of respondents. However,
increasing stigma is also cited as being the most likely negative outcome by
41% of the 17 people who responded negatively about the idea. 4 of 17
thought that full confidentiality may not be able to be maintained / adhered to
and 2 people thought that it might cause overcrowding and waiting times
would be longer. This theme was picked up by Focus Group 2 and debated
but the general consensus was that the increased number of clinics and wider
opening hours may act to reduce over-crowding.
7.2 Future Services: users’ and potential users’ views
The online survey asked participants where they thought future services
should be located and promoted. People were asked to provide their top three
choices and a total of 721 responses were made. The frequency of the
responses was fairly evenly spread, thus making a clear distinction between
them difficult. Being unmarked appears to be the issue of most importance
regardless of whether in a medical or non-medical setting (41.2%) Keeping
sexual health services anonymous through being unmarked and having them
in a medical setting was the most popular response to this question with a
quarter of responses 25.2%. Being anonymous and unmarked in a nonmedical setting followed with 16%.
Having services located in a main town centre shopping centre elicited 19%
and 17% wanted sexual health services near to public transport links.
Conversely, both focus groups concurred that attending a marked /named
service would not bother them and they would not be deterred from using
them. Focus group 1 thought that not naming a service a sexual health
service would contribute to confusion and Focus Group 2 thought that not
naming a service would contribute to keeping sexual health an
embarrassment.
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There were only a few ‘other’ suggestions and two people suggested having,
“..a mobile sexual health unit to reach people in rural areas.”
The young people in Focus Group 2 also brought up the positive aspects of
developing a mobile service as an issue. They thought that this would be a
service that they would use.
The online survey revealed that evenings and / or early mornings were the
two top choices for time of day preferred to attend sexual health or
contraception services with 39% and 27% respectively. However, the two
focus groups contradicted this as all the young people said that they thought
young people would not go to such a service in the early mornings. One
stated that, “It’s too early!”
However, they did say that they would consider it in the evenings. They
suggested that young people would be more likely to attend during the day or
after school or college. Both groups were aware of the needs of those people
working but they still felt that they would go at any time if they had a problem.
“If things were really bad and I was in pain, I’d go wherever.” (FG1)
There was an overwhelming positive response to the question as to whether
one would be likely to attend a service if it opened on a Saturday with 76.5%
agreeing (212/277). The young people’s focus groups were however divided
on this and generally erred on the side of suggesting that they’d not be likely
to go on a Saturday. Several people in both groups suggested that they’d go
on Sunday when the weekend was over. The age distribution on the online
questionnaire also supports the notion that younger people up to the age of
19 would be less likely to use a service on a Saturday morning compared to
people older than 25. The implications for targeting services at younger
people may have a bearing on whether Saturday opening hours are
considered.
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7.3 Recommendations: Access to future services
A. Involve stakeholders in designing more integrated and holistic sexual health
services in Surrey.
B. Design a hub and spoke model of service provision in Surrey and develop
clear service specifications for all services with detailed care pathways.
C. Pilot one-stop-shop services in Surrey as part of a range of service models
D. Undertake an unmet demand assessment in community contraceptive and
sexual health clinics.
E. Support the enablement of patient choice across Surrey by each service
reviewing their opening times and ensure that they are complementary to other
services. There should be an increase in services for adults that are open on
Saturday mornings.
F. Explore the feasibility of a central phone line/central booking of specialised
services in Surrey. This could include information and advice sessions where
people could speak to a specialised sexual health trained professional to ask
questions and / or raise concerns about their sexual health/sexual problems. A
helpline could be developed or people signposted to national helplines where
there is greater likelihood of 24/7 opening hours.
G. Ensure effective partnership working with the Youth Justice Service, the
Youth Development Service, Connexions and other young people’s
organisations to develop quality sexual health promotion activities with some
specific reference to Looked–After Children.
H. Develop training needs assessments of primary care staff such as GPs,
health visitors and midwives.
I.
Develop closer links between sexual health services and schools and
colleges and consider the development of on-site linked CASH services in
Surrey’s large colleges and the University and in targeted schools where this is
permitted.
J. Increase access to free condoms by making them available in places where
young people socialise, such as educational establishments. To consider how
condoms and Chlamydia screening can be incorporated into the night time
economy .e.g. clubs and pubs.
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8. Other reviews of Surrey services, evaluations and
recommendations
8.1 PCT reconfiguration
Since NHS reconfiguration in Oct 2006 and the establishment of Surrey PCT,
the management of GUM clinics, CASH services and the Chlamydia
screening programme have been simplified. This has resulted in significant
improvements in the co-ordination and integration of these services across
Surrey. This, along with the increased collaboration between all the GUM
clinics in Surrey to meet the 48 hours GUM access target, has led to overall
improvements in access to sexual health services. However, a number of
challenges prevail, notably the issue of payment by results (PBR). This
system is counter-productive to the unity of services, especially in light of the
fact that the 5 Surrey GUM Clinics are not equally funded and no tariff exists
for contraceptive services.
8.2 ‘Monday 4U’ service evaluation
The ‘Monday 4U’ service is a multi agency drop-in service for young people
aged 13 to 19 years old. It provides services around a range of health issues
including sexual health, and offers sexual health advice, EHC, condoms and
Chlamydia screening. It runs in youth venues in Redhill and Oxted. An
evaluation of the service shows it to be a success and highlights a link
between strong partnership working and positive feedback given by the young
people who use it. At present the numbers attending in Oxted are low. The
challenge is how to attract a large enough number of young people to the
service to make it economically viable. Any consideration of future location of
other such services needs to include a combination of relatively high
population, high teenage conception rates in relation to deprivation scores
and to be located in areas that lack other sexual health services.
8.3 Feedback from the Joint Area Review (JAR)
The recent inspection in relation to vulnerable young people and teenage
pregnancy identified a range of issues which have been incorporated into the
recommendations. In particular, the review identified the lack of GUM
provision in rural areas, the lack of one-stop-shops and the integration of
GUM with contraceptive services.
8.4 Feedback from National Children’s Bureau (NCB)’s evaluation of the
Surrey Teenage Pregnancy Strategy
In 2008, the Surrey Teenage Pregnancy Strategy Group commissioned the
National Children’s Bureau (NCB) to review the effectiveness of its Strategy in
light of the Joint Area Review’s findings that, ”the impact of Surrey’s Teenage
Pregnancy Strategy is inadequate”, especially in view of current upward
trends and inconsistencies since 1998 in the conception rate. To do this the
NCB review was broken down into several separate exercises. These
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included documentary analysis, some data collection, researching models of
good practice, conducting in-depth qualitative interviews with practitioners,
carrying out three case studies and exploring approaches adopted by
statistical neighbouring local authorities.
Successful activities cited by the review included the Condom Distribution
Scheme and drop-in sexual health services amongst other things. However,
for the purpose of this needs assessment their comments on sexual health
services are the only ones that have been highlighted here. These include:
concern that access to Long Acting and Reversible Contraception (LARC) and
Emergency Hormone Contraception (EHC) is not equitable due to differing
stances of GPs and pharmacists. The role of school nurses and youth service
was highlighted as key, as was the need to improve the way schools work
with young people who think they might be pregnant. The Youth Justice
Service was a partner identified as being missing from this work. It was also
noted that there had been a decline in 'hands-on' health promotion work
around sexual health, SRE and also for Looked–After Children.
There were some concerns expressed about how up-to-date the
contraception knowledge of frontline midwifery and health-visiting staff was,
with some anecdotal feedback having been received regarding the provision
of incorrect information. There was felt to be some resistance to and blocking
of the rollout of some sexual health schemes, such as sexual health delivered
through school based health clinics and this was attributed to individuals’
moral and political perspectives. These were also seen to hinder the
prescribing of some contraception methods by GPs and their ability to deliver
sexual health campaigns. Lack of public transport was also identified as an
issue affecting young people's access to sexual health services. This was felt
to be particularly difficult where young people needed to travel within
boroughs to services that were not located in urban centres.
Termination of pregnancies was one other area where support was
consistently cited as lacking and particular reference was made to post
termination services. There appears to be much enthusiasm for LARC locally
to bring down the repeat termination rates, which were universally described
as unacceptable. However it was reported that there is a distinct lack of
consistency in the provision of support for young people’s emotional well
being and physical health needs and concern that young people often don’t
attend follow-up appointments with their GP after their termination.
The review made 7 key recommendations all of which have been cited here
verbatim in the box below:
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Recommendations put forward by the National Children’s Bureau review
of the Surrey Teenage Pregnancy Strategy
1 Active engagement of all of the key mainstream delivery partners who
have a role in reducing teenage pregnancies – Health, Education, Social
Services , Youth Support Services and the voluntary sector
2 A strong senior champion who is accountable for and takes the lead in
driving the local strategy
3 The availability of a well publicised, young people-centered contraceptive
and sexual health advice service with a strong remit to undertake health
promotion work, as well as delivering reactive services.
4 A high priority given to PSHE in schools, with support from the local
authority to develop comprehensive programmes of sex and relationships
education (SRE) in all schools.
5 A strong focus on targeted interventions with young people at greatest risk
of teenage pregnancy, in particular with ‘Looked-After Children’.
6 The availability (and consistent take-up) of SRE training for professionals
in partner organisations such as Connexions Personal Advisers, Youth
Workers and Social Workers, working with the most vulnerable young
people.
7 A well resourced Youth Service that provides things to do and places to go
for young people, with a clear focus on addressing key social issues
affecting young people, such as sexual health and substance misuse.
8.5 Evidence base for the development of One Stop Shops
The results of the national evaluation of one-stop-shops (OSS) have been
published and key recommendations include:
- Having an integrated mindset was viewed as just as important as the
establishment of OSS.
- Having a hub and spoke model with clear referral pathways was important to
consider when developing OSS.
- In the main OSS are acceptable to many users provided they provide access
to different users (e.g. separate services for young people). Some individuals
and targeted groups (such as gay men) favour stand-alone specialist services.
- The establishment of OSS should not be at the expense of local satellite
services or choice of providers. A reduction of services may reduce access to
the most vulnerable and least vociferous groups.
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9. Next Steps
9.1 Stakeholder involvement
This needs assessment will be presented to stakeholders at a visioning event
to be held in October 2008, facilitated by the Department of Health National
Support Team.
The key outcomes will be to review the current sexual health strategy, design
a model of holistic, integrated sexual health services for Surrey and to develop
a commissioning framework that will enable services to meet need.
9.2 Contributors to the needs assessment
Michael Baker and Joanne Greenaway would like to thank the following
people for their contributions towards the development and implementation of
the ‘it takes you tango’ survey and the gathering of and analysis of data for
this needs assessment and report:
Katie Anders
Helen Atkinson
Chris Botten
Dr Liz Brutus
Dr Emmanuel Edet
Sally Elkes
Debbie Gordon
Emma Jacobs
Becky Kite
Dr Rachel Mearkle
Karen Nicholls
Carol Rowley
Livia Royle
Lynne Sawyer
Dawn Scully
John Stephen
Chris Willson
Ian Cole
Sue Whitfield
Health Protection Agency
Surrey PCT
Surrey PCT
Surrey PCT
Surrey County Council
Surrey Community Health Services
Frimley Park Foundation NHS Trust
Surrey Community Health Services
Surrey PCT
Surrey PCT
Surrey Community Health Services
Surrey PCT
Surrey PCT
Surrey PCT
Surrey County Council
Surrey PCT
Surrey PCT
Surrey PCT
Surrey PCT
In addition, it would not have been possible without the people who gave up
their time to provide their views about current and future sexual health
services in Surrey:
Users and potential users
Young people & staff
Young people & staff
‘It takes you to Tango’ survey
Guildford YMCA Youth Group
Surrey Youth Justice Service
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References
1
Department of Health (2000) National Strategy for Sexual Health and HIV. London
: DOH.
2
Department of Health (2008) Vital Signs- Operational Plans 2008/09 - 2010/11 London:
DOH.
3
Healthcare Commission (2008) Existing commitment indicators for primary care trusts.
London: Healthcare commission.
4
Department of Health (2004) Choosing Health-Making Healthy Choices Easier London:
DOH.
5
National Institute for Health and Clinical Excellence.(2005). Longer-Acting Reversible
Contraception (Guidelines 30). London: NICE
6
Medical Foundation for Aids and Sexual Health (2005) Recommended Standards for
Sexual Health Services. London: MedFASH.
7
University College London (2007) Evaluation of One Stop Shop Models of Sexual Health
Provision: London: UCL
8
Office for Standards in Education ((2008) Joint Area Review of services for Children in
Surrey London: Ofsted
9
NCB (2008) Evaluation of the Surrey Teenage Pregnancy Strategy
10
Design Options (2007). Sexual Health Needs Assessments (SHNA) - A How to Guide.
London: DOH.
11.
Miles, M. B and Huberman, A. M (1994) Qualitative Data Analysis, Sage Publications:
London
12
Horizontal Equity = Equal service provision for the same needs.
13
Vertical Equity = Service provision on the basis of needs. This may require treating
differently the population groups with different levels of need.
14
15
NCB (2008) Evaluation of the Surrey Teenage Pregnancy Strategy
Health Protection Agency (2007) Testing Times: London
16
Department of Health, (2001) Sexual Health and HIV Strategy London: The Stationary
Office.
17
Hickson, F., Nutland, W., Weatherburn, P., Burnell, C., Keogh, M., Doyle, T., Watson, R.
and Gault, A. (2003) Making it count: A Collaborative planning framework to reduce the
incidence of HIV infection during sex between men Sigma research, London,
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Contract Details
Public Health, Surrey PCT
Pascal Place, Randalls Way, Leatherhead
Surrey KT22 7TW
www.surreyhealth.nhs.uk
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