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National Enhanced Service - more specialised sexual health services

2 May 2003

Introduction
1. All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.

Background
2. The past decade has seen substantial increases in high-risk sexual behaviours in the UK population. During the 1980s and early 1990s, new diagnoses of sexually transmitted infections (STIs) declined, but since 1995 STIs including HIV have risen and diagnoses of chlamydia, gonorrhoea and syphilis have doubled in the past five years. Teenage pregnancy rates in the UK are the highest in Western Europe.

3. Data are also available from the National Survey of Sexual Attitudes and Lifestyles (Natsal 2000)** which can be compared with information from a similar survey undertaken in 1990. This shows that between the two surveys there had been an increase in behaviours associated with increased risk of HIV and STI transmission, including increases in numbers of partners and concurrent partnerships. In particular, there were considerably higher rates of new partner acquisition among those younger than 25 years and this is reflected in the substantially higher incidence of STIs in this age group.

4. Sexual ill health has great human and economic costs. The Department of Health document ‘Effective commissioning of sexual health and HIV services’ (January 2003) provides the following data:
(i) chlamydia causes pelvic inflammatory disease, infertility and ectopic pregnancies
(ii) HIV is a chronic, life-threatening condition costing an average of between £135,000 and £181,000 to treat over a lifetime
(iii) teenage pregnancy can compound social inequalities faced by the mothers and their children
(iv) open access contraceptive and GUM services are in place, but are greatly overstretched and much need is currently unmet.

5. The importance of primary care in an enhanced sexual health strategy is demonstrated by the facts that:
(i) about 75-80 per cent of contraception is provided in primary care
(ii) more than a third of women found to have chlamydia (the most common bacterial STI in the UK) were diagnosed in primary care
(iii) primary care is highly accessible to all people including young women, and primary care is well accessed by many who may be at risk of HIV.

Service outline
6. Service delivery should be informed by relevant national strategies, such as (in England) the Social Exclusion Unit Teenage Pregnancy Report (June 1999), the Best Practice Guidance on the Provision of Effective Contraception and Advice Services for Young People, published as part of the Teenage Pregnancy Strategy in 2000, and the National Strategy for Sexual Health and HIV (July 2001) and the Strategy Implementation Action Plan (June 2002).

7. Each Primary Care Organisation should consult with all relevant stakeholders, to determine the service models and standards of care appropriate to its local population with respect to minimum standards of prescribing (formulation, dose, drugs of limited value etc), attendance and follow-up rates, hepatitis B testing and immunisation rates, partner notification etc. Care pathways should be agreed with stakeholders, and all should be made aware of these pathways. The pathways should include guidance with respect to other relevant services. These should be used as part of the audit and monitoring criteria for the national enhanced service.

8. This national enhanced service will fund:
(i) a service for HIV testing, including pre and post test counselling
(ii) STI screening and treatment using the most reliable testing methods available
(iii) the practice to act as a resource to colleagues in sexual health care in primary care
(iv) the training of GPs and GP registrars, practice nurses and other relevant staff (such as health advisors)
(v) effective liaison with local sexual health services and cytology and microbiology laboratory support and other statutory or non-statutory services where relevant (such as young people’s services)
(vi) additional training and continuing professional development for clinicians commensurate with the level of service provision expected of a clinician in line with any national or local guidance to meet the requirements of revalidation
(vii) records kept on the advice, counselling and treatment received by patients. It is the clinician’s responsibility in conjunction with the patient to agree what to enter in the lifelong patient notes
(viii) a register of all patients being treated under the enhanced service
(ix) appropriate arrangements for review
(x) costs of condoms, pregnancy testing kits and other additional resources or referral costs
(xi) treatment of STIs without prescription charge
(xii) effective communication with all young people including young men, gay and lesbian people, and ethnic minorities
(xiii) a holistic approach to assessment of risk of STI, HIV and/or unplanned pregnancy, including consideration of other relevant health problems such as drug misuse or mental health problems
(xiv) the provision of information on, testing and treatment for all STIs (excluding in the case of testing and treatment HIV infection, syphilis, Hepatitis B and C or treatment-resistant infections)
(xv) the assurance of partner notification of relevant infections by adherence to agreed guidance
(xvi) a sound understanding of the role of different professional groups in the shared care of HIV positive patients, and those at risk of HIV
(xvii) suitable training for all staff involved with patients seen for sexual health and HIV-related conditions
(xviii) review. All practices undertaking this service will be subject to an annual review which could include an audit of:

(a) the number of patients seen for specific interventions
(b) the number of people screened and treated effectively
(c) attendance rates for each service offered
(d) gestation at abortion and follow-up contraception rates
(e) the number of at-risk individuals tested and immunised according to local guidance for blood-borne viruses
(f) age, gender, sexuality and ethnicity of patients to ensure that those most at risk from unplanned pregnancy and poor sexual health are accessing the practice.

Accreditation
9. Those doctors who have previously provided services similar to the proposed enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so.

Costs
10. In 2003/04 each practice contracted to provide this service will receive an annual retainer of £2,000 plus an annual payment of £200 per HIV positive patient (paid quarterly in arrears) and £100 per other patient (paid quarterly in arrears.) These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.

** Johnson A, et al. Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. Lancet 2001; 358: 1835-42