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Tackling the sexual health crisis head on

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Judith Chamberlain-Webber

Sexual health

Sexual health
Government has had its sights set on improving sexual health for some years now but, if the latest statistics are anything to go by, there is still a long way to go.

Data published by the Health Protection Agency in November last year disclose a worrying rise in sexually transmitted infections (STIs) and high rates of HIV, including an 8% rise in chlamydia infections between 2002 and 2003 (Box 1; Table 1).

This may be why the Government launched a two-pronged attack on the problem in November 2004: the public health White Paper and a promise of a new £300 million programme over three years, to modernise and transform sexual health services in England.

The extra funding will include a £50 million advertising campaign to tackle the rise in STIs, the biggest on sexual health in 20 years.

The Government is increasingly looking to other parts of the health service to help relieve the pressure on sexual health services.

This means more and more nurses may start to find themselves having to give sexual health advice and care on a daily basis in various settings from GP practices, community-based clinics, outreach services and walk-in centres to accident and emergency departments.

Background to policies
In the past few years, there has been a range of policy initiatives introduced in England by the Government. Scotland, Wales and Northern Ireland have also introduced policy in this area.

Teenage pregnancy In 1999, the Government in England launched its Teenage Pregnancy Strategy to address the growing numbers of unwanted pregnancies, set out in the Social Exclusion Unit report on teenage pregnancy. It also set up the Teenage Pregnancy Unit, which is a cross-government unit located within the Department for Education and Skills. The two national targets are to:

- Halve the under-18 conception rate in England by 2010 (with an interim reduction target of 15% by 2004 included in The NHS Plan, which is also a manifesto commitment), as part of a broader strategy to improve sexual health

- Increase the participation of teenage parents in education, training or work to 60% by 2010 to reduce the risk of long-term social exclusion.

In 2000, the Independent Advisory Group on Teenage Pregnancy, a non-statutory body, was established to provide advice to the Government and monitor the overall success of the Teenage Pregnancy Strategy.

Sexual health and HIV strategy In July 2001, the Government in England published the sexual health and HIV strategy for consultation, Better Prevention, Better Services, Better Sexual Health: The national strategy for sexual health and HIV. This was the first-ever national strategy on sexual health and HIV. The strategy aimed to:

- Reduce the transmission of HIV and STIs

- Reduce the prevalence of undiagnosed HIV and STIs

- Reduce unintended pregnancy rates

- Improve health and social care for people living with HIV

- Reduce the stigma associated with HIV and STIs.

In 2002, the Government developed a 27- point action plan, entitled The National Strategy for Sexual Health and HIV Implementation Action Plan, which provided a framework for delivery. Sexual health strategies have also been published for Wales and Scotland.

Chlamydia screening Genital Chlamydia trachomatis is the commonest sexually transmitted infection in England and an important reproductive health problem that can lead to infertility, ectopic pregnancy and pelvic inflammatory disease.

National opportunistic screening for chlamydia in sexually active women and men under 25 years of age was promised in the national strategy and in September 2002, the first phase of the programme began following the results of a successful year-long pilot study which was carried out in the Wirral and Portsmouth.

The first phase covered 10 programme areas and in January 2004 a further 16 programmes were announced, taking the coverage up to 25% of PCTs in England (Figure 1).

Advisory group In March 2003, the Government set up an Independent Advisory Group on Sexual Health and HIV. The group, which provides a wide range of views from health pro- fessionals involved in all aspects of sexual health, was set up to monitor progress and advise the Government on implementation of the Sexual Health and HIV Strategy.

Abortions The Government target set for primary care trusts as part of their performance ratings is for 60% of NHS-funded abortions to be carried out within nine weeks. Department of Health guidelines also say pregnant women seeking an abortion should wait no more than three weeks after the point at which they present to a GP.

Results of initiatives
Despite these initiatives, in June 2003, the House of Commons Health Select Committee published a damning report on the state of sexual health. It warned of a sexual health crisis and urged the Government to take serious action. The committee called on the Government to:

- Introduce a national service framework on sexual health and immediately 'tackle sexual health as a public health priority at a strategic health authority level'

- Introduce a target of 48 hours for patient access to genitourinary medicine (GUM) after the report found that the average waiting time for sexual health services is 10 to 12 days

- Introduce a nationwide screening programme for chlamydia, increased prioritisation for contraceptive services and a better level of service on offer to patients at GUM clinics.

What has happened since then?
Teenage pregnancy

The Independent Advisory Group on Teenage Pregnancy published its third annual report in December 2004. Although the strategy on reducing teenage pregnancies is working, the Government must intensify its efforts and be bolder if it is to meet its goal of halving the under-18 conception rate by 2010, say the group.

The overwhelming majority of local authorities have achieved downward trends in their teenage conception rates, sex education has improved and more young parents are returning to education. There has been a reduction of 9.4% in under-18s conceptions since 1998 but teenage pregnancy rates are still the highest in Western Europe.

Chlamydia screening programme

The length of time taken to roll out the screening programme has attracted much criticism from public health experts and there has been a lot of concern over lack of funding for the programme and proper testing.

A third phase of implementation was due to be launched in the autumn of 2004 but this has now been superseded by the Government's public health White Paper commitment, which means the programme will have to be accelerated to meet the new target.

A report of the first full year of screening was published last autumn. It revealed that 10.1% of women are positive and 13.3% of men. The results confirmed that opportunistic screening outside GUM clinic settings does work in a variety of places such as GP surgeries, colleges and young persons' drop-in centres.

Abortions

There are significant variations in abortion services both in terms of waiting times and NHS funding. A survey commissioned by Parliament's all-party pro-choice and sexual health group in June 2004 showed that just 51% of abortions funded by the NHS were carried out in the first 10 weeks of pregnancy.

Almost one-third of abortion services treat all abortion patients in 14 days or fewer but the aim is to reduce this towards one week. More than 25% of PCTs still have an unacceptable waiting time of more than three weeks for women requesting abortion.

New policy initiatives
Choosing Health White Paper

Much to many people's relief, the Government decided to include sexual health policy in its public health White Paper despite its controversial omission from the second Wanless report Securing Good Health for the Whole Population, earlier last year.

Published in November 2004, the White Paper lists a range of commitments and action to address the problem. These include:

- Further action on chlamydia, including the fast tracking of the national screening programme and also piloting screening in areas not traditionally used, such as pharmacies. The programme will cover the whole of England by March 2007. A further £80 million will be allocated to help achieve this

- Modernising genitourinary medicine (GUM) clinics, with an injection of a further £130 million over three years, and upgrading prevention services such as contraceptive services - with another £40 million put toward this

- By 2008, everyone referred to a GUM clinic should be able to have an appointment within 48 hours - a target that is currently only met for 38% of attendances

- Improving sexual health has been included within the framework for national targets for the NHS (2005-06/2007-08) and will be included in the forthcoming round of local delivery plans

- Contraceptive services are patchy and in some places virtually non-existent. An audit of contraceptive service provision is due to start now and investment made to meet gaps in local services

- A three-year Young People's Development Programme to pilot ways of reducing teenage pregnancy and improving sexual health, particularly among vulnerable young people

- A broader reach of information about sexual health for young people in ways that they can access such as a confidential email service offered by trained sexual health advisers, increased support for parents in talking to children about sex and relationships and provision of advice in settings where young people go

- Breaking down the boundaries between primary and specialist services.

Reviewing services
The DH has asked The Medical Foundation for AIDS and Sexual Health (MedFASH) (previously known as the BMA Foundation for AIDS) to carry out three projects:

1. To manage a national review of genitourinary medicine (GUM) services, as part of the implementation action plan for the National Strategy for Sexual Health and HIV. Initiated in partnership with the British Association for Sexual Health and HIV (BASHH), the project began in June 2004 and will last for two years.

2. To recommend standards for NHS HIV services. These standards have now been published and cover 12 aspects of service provision for people with HIV and offer guidance on managed service networks.

3. To recommend standards and networks for sexual health services. Consultation on the draft recommended standards has finished and publication is expected soon (Box 2, page 10). The sexual health service networks project is expected to last until the end of this month.

Impact on nurses
Despite the National Strategy for Sexual Health and HIV, which set out how practice nurses and school nurses can play an important role in its delivery, nurses' full potential is not being reached. There are three levels of activities with which nurses could become involved:

- Factual sexual health education targeted at young people and at-risk groups

- Opportunities to screen those with no symptoms

- Early diagnosis and treatment of those infected.

Choosing Health also outlines several areas where nurses' roles could be developed:

- Flexible multidisciplinary teams could be headed by nurses linking between contraception, sexual health specialists (including GUM specialists) and community, youth services and sexual health liaison workers working with primary care providers

- The roles of nurses could be extended to include elements of sexual health

- Mainstream primary care health programmes could be delivered by school nurses, health visitors, community psychiatric nurses, midwives and practice nurses

- More primary care practitioners with a special interest could work alongside sexual health experts.

These could be delivered in different settings to ensure hard-to-reach or at-risk groups are targeted such as:

- One-stop shops combining treatment and prevention services

- Health buses, community pharmacies

- Screening and testing centres in sports centres, shopping malls, workplaces, universities and community centres.

An evaluation of one-stop shops is currently being carried out by a team from University College London and Bristol University, which is due to report in 2006.

The Government is keen to see a greater role for primary care. However, a survey of gay men published last summer revealed that many do not go to see their GP for sexual health information and less than half are 'out' to the staff in their GP's surgery. There also appears to be a serious shortage of nurses with appropriate sexual health learning and skills to fulfil these roles, says the Royal College of Nursing. A range of resources to help nurses are listed in Box 3 (page 13).

The future
There is clearly a lot that still needs to be done. The key areas for the future are improved education and prevention work, particularly for HIV, and making sexual health an issue for mainstream services.

Many groups want to see specific and measurable targets published for sexual health so that it does not become pushed to the bottom of the priority list by PCTs. Sexual health also will need to be dovetailed into other policies such as payment by results, patient choice, and chronic disease management.

The Independent Advisory Group has also made a number of recommendations for the future in its annual report 2003/04. Box 4 (below) lists those of particular relevance to nurses.

Conclusion
Despite repeated efforts over the past few years, the sexual health crisis seems to continue unabated. Nurses working in a range of settings but especially primary care must ensure that they have sufficient training to meet the demands that are going to be placed upon them. This is clearly not a problem that is going to go away.

Further information - Conference
Achieving Excellence in Sexual Health Training
Tuesday April 26, Sheffield

A free conference to showcase good practice in sexual health training and to launch the National Quality Standards for Sexual Health Training and the National Sexual Health Training Manual.

Organised by the Centre for HIV and Sexual Health, South East Sheffield Primary Care NHS Trust. Details: www.sexualhealthsheffield.co.uk Tel: 0114-2261904.

Developing Patient Partnerships (www.dpp.org.uk)
The Sex SOS 'Sussed On Sex' sexual health campaign begins in spring and intends to tackle the embarrassment factor in sexual health. A website aimed at 16-24-year-olds is being developed and will direct them to confidential and hassle-free sexual health information and services. Local initiatives will promote the site, www.sussed.uk.net

Websites and sources of further information
Scotland: www.scotland.gov.uk/library5/health/shst-00.asp

Northern Ireland

www.healthpromotionagency.org.uk/Work/Sexualhealth/

www.dhsspsni.gov.uk/phealth/sexualhealth.asp

England: www.dh.gov.uk/PolicyAndGuidance/Health AndSocialCareTopics/SexualHealth/fs/en

Wales: www.cmo.wales.gov.uk/content/work/health-challenge-wales/index-e.htm

Choosing Health White Paper: www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications PolicyAndGuidance/PublicationsPolicyAndGuidance Article/fs/en?CONTENT_ID=4094550&chk=aN5Cor

HPA statistics: Focus on Prevention: HIV and other Sexually Transmitted Infections in the United Kingdom in 2003. Annual Report, November 2004

www.hpa.org.uk/infections/topics_az/hiv_and_sti/ publications/annual2004/annual2004.htm

National Chlamydia Screening Steering Group: First Steps. Annual Report of the National Chlamydia Screening Programme in England 2003/04. DH, 2004.

Terrence Higgins Trust: www.tht.org.uk

Gay Men Survey: www.sigmaresearch.org.uk/downloads/report04d.pdfKEY POINTS
Sexual health

- The sexual health crisis has not yet been adequately tackled

- Sexual health needs to become part of mainstream services

- Nurses are going to be expected to be more involved with providing advice and support to young people and people in at-risk or hard-to-reach groups.

Sexual health statistic
Over 400 000 new sexually transmitted infections (STIs) are diagnosed in GUM clinics each year in England alone (Independent Advisory Group for Sexual Health and HIV, 2004)

Sexual health statistic
Diagnoses of HIV increased by nearly 200% between 1996 and 2002, and cases of chlamydia increased by over 140% between 1996 and 2002 (Health Protection Agency, 2004)

Sexual health statistic
New episodes of STIs diagnosed in GUM clinics in England, Wales and Northern Ireland has risen from 708 538 in 1992 to 1 533 816 in 2002 including increases in gonorrhoea (up 148%), chlamydia (up 195%) and infectious syphilis (up 380%). (IAG, 2004)

Approaches to sexual health in Scotland, Northern Ireland and Wales
Northern Ireland

The Department of Health, Social Services and Public Safety (DHSSPS) has identified sexual health as an area to be addressed under 'Investing for Health'. The DHSSPS has also drawn up a Teenage Pregnancy and Parenthood Strategy Document from 2002-2007. Development of a comprehensive sexual health strategy commenced in March 2003.

The Health Promotion Agency continues to run its sexual health information campaign aimed at increasing awareness of safer sex for 18-30-year-olds. It also works closely with the DHSSPS to implement the Sexual Health Promotion Strategy, which aims to reduce the number of new diagnoses of HIV/STIs by 25% by 2009.

Scotland

In response to growing concerns about Scotland's sexual ill health, in August 2002 the Minister for Health and Community Care appointed an independent expert reference group to draw up a strategy for improving sexual health in Scotland. The consultation process was launched in November 2003 and completed in April 2004. In light of this consultation exercise, entitled 'Enhancing Sexual Wellbeing in Scotland: A sexual health and relationships strategy', the Scottish Executive published Respect and Responsibility: Strategy and action plan for improving sexual health at the end of January 2005. This document is both a strategy and a practical plan for action to:

- Promote respect and responsibility

- Prevent sexually transmitted infections and unplanned pregnancy through education, service provision and support

- Provide better sexual health services which are safe, local and appropriate. Wales

The Welsh Assembly Government has invested more than £3 million in sexual health over the past three years, putting into practice the strategic framework for promoting sexual health in Wales. Work includes the implementation of new local sexual health strategies, a national sexually transmitted infections prevention campaign and the development of HIV antenatal screening in Wales.

At the end of last year, following a review into the state of HIV and sexual health services, the Health and Social Services Minister Jane Hutt announced further wide-ranging action to strengthen HIV and sexual health services in Wales.

This includes better integration of services with clear standards. There will also be a target for local health boards and trusts to ensure access to testing for sexually transmitted infections within two working days. Spending for sexual health services will be protected. Sexually transmitted infection is one of the key themes of Health Challenge Wales, the national focus for action to improve health in Wales.

Sexual health statistic
Unwanted pregnancy costs the UK £2.5 billion a year and the lifetime cost of caring for the new HIV cases diagnosed in 2002 and 2003 is put at £1 billion. STIs and their complications also cost over £1 billion a year. (IAG, 2004)

Kathy French, Part-time Sexual Health Adviser, Royal College of Nursing
'Nurses can and are playing a key role in sexual health and many are extending their roles within sexual health.

'Public health policy is driving ahead these changes. Inner-city services in GU are stretched to their limits and this places additional pressures on general practices to provide sexual health for their populations. However, while staff in some general practices are providing sexual health care, others do not have the skills and training to deliver an effective service.

The RCN has produced the first ever competency framework in collaboration with other nursing and medical colleagues. This framework will assist nurses and their managers to plan their development within sexual health from novice to expert. The framework is available on the RCN website (www.rcn.org.uk). The RCN has also produced a distance learning skills course in sexual health for nurses who are working at a basic level and it is hoped that 1000 will be trained by end of the year. Details are available on the website.

'Like other aspects of service delivery, sexual health has problems with recruitment of nurses and doctors and this is one of the key challenges for the service.

'I would really like to see sexual health included in the pre-registration curriculum because often students are not getting any exposure to clinics, although there are a few exceptions.

'It's a really exciting time for nurses in sexual health and they have many opportunities to extend their roles. They need to embrace these changes.'

Vanessa Griffiths, Nurse Consultant in Sexual Health, City Hospital, Nottingham
'Many of our sexual health services have nurse practitioner clinics. Nottingham is one of the screening areas for chlamydia, a programme which is predominantly run by nurses and we have nurse practitioners working in our clinic who sees new patients.

'We have also just introduced a mini-screen programme for male patients to come in without an appointment for sexual health screening, which is run by non-registered nurses trained through the competency framework.

'We work with community midwives and offer chlamydia screening for ante-natal patients. There is also a nurse-led follow-up clinic which is run as an open access clinic because we find attendance is much higher than with an appointment system.

'If we are going to meet the 48-hour target, nurses should be actively encouraged to become involved and do more than just be wart painters or phlebotomists. I think Agenda for Change should address some of these issues.

'More patients who are asymptomatic could be seen in primary care. For example, if practice nurses are seeing someone for a cervical smear aged under 30 and not in a regular relationship, screening for STIs could be offered.'

Will Nutland, Head of Gay Men's Health Promotion, Terrence Higgins Trust
'We do need to deal with the sexual health crisis in a much more integrated way. A concern, however, is the shift of focus away from GUM clinics, and some key groups could suffer as a result. For example, gay men are very used to using GUM services, and may not choose to disclose their sexual orientation to their GP. So we do need to offer more choice and more accessible services, but make sure that the choice is acceptable to all our key STI risk groups.

'Nurses in general practice in particular can take small but significant steps in using gender neutral terms and reassuring people that they are willing to speak about sexual health matters whatever that person's sexual orientation.'

'The Department of Health should be complimented for resourcing a £50 million advertising campaign among the general public to raise awareness of the risk of STI. But we should be clear about who STIs are impacting on the most. The main groups affected by HIV are gay men and the African migrant community, and we would promote a targeted approach to health promotion rather than general messages through the mass media.

'There is a danger of overplaying risks to the general population. For example, there has been an 8% increase in diagnosis of chlamydia in England, due to better awareness raising and a pilot screening project, and a decrease of 4% in detected cases of gonorrhoea. But for men who have sex with men, over the same period, there was an increase in chlamydia of 22%, and an 11% increase for gonorrhoea.'

Sexual health statistic
Studies in England suggest approximately a third of patients with symptomatic STIs continue to have unprotected sexual intercourse. (Health Select Committee, June 2003/HPA, June 2003)

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