Guidance for the development of specifications for the
Guidance for the development of specifications for the commissioning of chlamydia screening in General Practice and Community Pharmacy March 2010 Acknowledgements Development of this guidance document would not have been possible without the advice and guidance of the project group. Project Group Membership Claire Tyler Consultant to the Screening Programme National Chlamydia Paula Baraitser National Chlamydia Screening Programme, Medical Advisor Marie Kernec National Chlamydia Screening Programme Manager Lynn Wilson DH Policy Team, Commissioning Framework Lead Rosie Gagnon Chair of the English Commissioners Group for HIV and Sexual Health Vivienne Parish Sexual Health Commissioner, Coventry Sukhdip Mahil Sexual Health Commissioner, Derbyshire Ali Young Sexual Health Commissioner/ Lambeth Sebastian Kalwij National Chlamydia Screening Programme, GP Lead London Ted Hiscock National Chlamydia Screening Programme, GP Lead West Midlands Evelyne Beech National Chlamydia Screening Programme, Pharmacist Lead South West Mark Anyaegbuna National Chlamydia Screening Programme, Pharmacist Lead London Debbie Harvey National Chlamydia Screening Programme, Regional Facilitator Patrick Lenehan National Chlamydia Screening Programme, Regional Facilitator Simon Henning Cheshire & Merseyside Sexual Health Network Lead 1 Introduction The National Chlamydia Screening Programme (NCSP) in England was established in 2003. It offers free opportunistic screening, treatment and partner management and prevention to sexually active young men and women under the age of 25. The goal of the programme is to: 2 Prevent and control chlamydia through early asymptomatic infection; Reduce onward transmission to sexual partners; Prevent the consequences of untreated infection. detection and treatment of The NCSP is managed by the Health Protection Agency. All 152 NHS Primary Care Trusts (PCTs) in England have received Department of Health (DH) funding to commission local chlamydia screening programmes. The NCSP has produced guidance1,2 to support PCTs in the delivery of the programme including specific advice for general practice and community pharmacy3,4. This document is designed to complement these. 1.1 Background Genital chlamydia infection is the most commonly diagnosed bacterial sexually transmitted infection (STI) in England. Prevalence of the infection is highest in sexually active young men and women under the age of 25 years. Untreated infection can have serious long-term consequences. In women it can lead to pelvic inflammatory disease (PID), ectopic pregnancy and tubal infertility. In men it can lead to epididymitis and epididymo–orchitis. In both men and women it can lead to Reiter’s Syndrome. The infection often has no symptoms but is easy to diagnose and treat. Treatment and partner notification can reduce complications which are estimated to cost the NHS millions of pounds per year. 1.2 The target The 2009/10 and 2010/11 targets for chlamydia screening are 25 and 35 percent of men and women aged 15-24 tested in healthcare and non healthcare settings, excluding genitourinary medicine (GUM) activity5. PCTs are performance managed on meeting this target which forms part of the ‘Annual Health Check’ as part of the broader ‘Strategy for Sexual Health’. The longer term aim is to achieve at least 35 – 50 percent coverage through testing alongside treatment, partner notification and prevention. Modelling studies indicate that screening rates between 26-43 percent, along with high rates of partner notification and management, will be needed to bring about significant reductions in prevalence6. 1.3 Context – the role of general practice and community pharmacy The role of general practice and pharmacies in providing chlamydia screening, treatment and partner notification is well established. Since the launch of the programme general practice and, to a lesser extent, pharmacies have generated increasing proportions of annual screening numbers. However, it is clear that in most areas the potential of these services to provide screening, treatment and partner notification is not being fully utilised. General practice has a crucial role to play in promoting sexual health. Most young people visit their GP at least annually7,8 yet in 2008/09 only 15% percent of screens nationally came from general practice with wide regional and local variation in their engagement in the programme. Community pharmacies are likely to play an increasing role in the services building on the success of pharmacy-based emergency programmes. The 2008 Pharmacy White Paper9 includes a range of contribution that pharmacies can make to sexual health services 3 delivery of sexual health hormonal contraception specific proposals on the nationally. In 2008/09 2 percent of screens came from pharmacies with wide regional and local variation in their engagement in the programme. Maximising the capacity of both general practice and community pharmacy to deliver chlamydia screening, treatment and partner management is likely to be a cost effective strategy. Indeed as the DH chlamydia screening pilot demonstrated, high screening coverage is feasible when core community based services are major contributors. Core community based services can be defined as the following: Contraception and Sexual Reproductive Health services Abortion services General Practice Community Pharmacy If the currently engaged core community service venues tested at least one person a day, over 1.8 million young people would be tested in a year. This equates to approximately 26% coverage of the 15-24 year old population generated through core services alone. If engagement of core services increased to 60% and each of them tested one young person a day, close to 4 million young people would be tested each year which would afford 58% coverage of the 15-24 year old population. 1.4 Guidance development In order to develop this guidance document a project group was established with a formally invited membership and agreed terms of reference. The group comprised the NCSP Medical Advisor and Programme Manager, NCSP GP and Pharmacy Champions, NCSP Regional Facilitators, Chair of the English Sexual Health & HIV Commissioners Group, the DH Sexual Health Commissioning Framework lead, PCT Sexual Health Commissioners and a Sexual Health Network lead. The project group’s remit was to provide advice and support on the content and development of the guidance document. 1.5 Developing service specifications In order to support commissioners in the commissioning of chlamydia screening in general practice and pharmacies this document contains detailed information that commissioners may wish to include in their service specifications. All specifications should align to the GMS/PMS/APMS Contracts10 for general practice and the NHS Community Pharmacy Contractual Framework. Financial data which may be of interest to commissioners in the development of service specifications is not contained within this document but is available seperately12. Chlamydia screening should be commissioned as part of a wider sexual health pathway. Services which act as a trigger for providing a chlamydia screening test and which commissioners are likely to want to include within the service specifications developed for use in general practice and community pharmacy include: Sexual health advice and promotion The provision of Emergency Hormonal Contraception (EHC) The provision of condoms 4 1.6 Adolescent / youth health issues HPV vaccination programme The provision of contraception including long acting reversible methods (LARCs) The screening and treatment of other STIs. Application of this guidance document The aim of this guidance is to support both commissioners and service providers in achieving high quality chlamydia screening services for the population they serve. It is hoped that it will support standardisation of commissioning, collaboration between PCTs or programme areas, equity of service provision, flexibility for local development and most importantly support PCTs in the delivery of the chlamydia screening target. Information included is considered core and generic and would therefore be appropriate for all specifications including those where cluster arrangements exist between PCTs. It is likely that PCTs will want to supplement this information with requirements relevant to their local area based on detail that will be identified from local Sexual Health Needs Assessment including local priorities, local models of service provision and the resultant care and referral pathways. For community pharmacy, it complements the NHS Community Pharmacy Contractual Framework - Enhanced Service guidance published in 2008 and updated in 201013. 2 Suggested information to include in service specifications 2.1 Programme Aims The National Chlamydia Screening Programme (NCSP) in England was established in 2003. It offers free, opportunistic screening, treatment and partner management and prevention to sexually active young men and women under the age of 25. The development of community based chlamydia testing, treatment and partner notification services will support the development of sexual health services in primary care and will help to achieve the population based chlamydia screening at rates of the 35 - 50 percent coverage necessary to reduce prevalence. The goal of the National Chlamydia Screening Programme (NCSP) is to: 5 2.2 Prevent and control chlamydia through early asymptomatic infection; Reduce onward transmission to sexual partners; Prevent the consequences of untreated infection. detection and treatment of Evidence Base The National Strategy for Sexual Health & HIV14 highlighted the rising trend of sexually transmitted infections, the relationship between sexual ill health, poverty and social exclusion, and the varying standards of service provision. Nationally the most commonly diagnosed bacterial sexually transmitted infection is chlamydia with the highest rates in the 16-24 year old age group. Untreated infection can have serious long-term consequences. In women it can lead to pelvic inflammatory disease (PID), ectopic pregnancy and tubal infertility. In men it can lead to epididymitis and epididymo-orchitis. In both men and women it can lead to Reiter’s Syndrome. The infection often has no symptoms but is easy to diagnose and treat. 2.3 General Overview In his ‘Next Stage Review’ Lord Darzi15 described four themes for the NHS over the next 10 years. These themes are the framework for a health and care system that is fair, personalised, effective and safe. Improving sexual health is included in his review as one of the six key goals. World class commissioning will be pivotal in reducing health inequalities and will support the shift from treatment to prevention. This is essential as lifestyle choices have been identified as responsible for up to 50% of the gap in health inequalities. The ‘Our Health Our Care Our Say16: a new direction for community services’ White Paper publication identified the need to improve sexual health provision as a key priority for primary care. The 2008 Pharmacy White Paper9 includes a range of specific proposals on the contribution that community pharmacies can make to sexual health services nationally. The ‘You're Welcome’ Quality Standards17 have been developed from examples of effective practice and offer a framework for improving access to health care services for young people aged 11-20 years. The Independent Advisory Group for Sexual Health and HIV identified the commissioning process as a priority to effective sexual health service delivery in their review of the Strategy for Sexual Health and HIV18. The Operating Framework 2009/1019 identifies two sexual health indicators as Vital Signs: Chlamydia screening (VSB13) Reduction in unplanned teenage pregnancy (VSB12). 2.4 Objectives The objective of commissioning services for chlamydia in general practice and community pharmacy are: 6 2.5 To increase testing of sexually active men and women under 25 years of age attending general practices or community pharmacies. To increase understanding and awareness of the importance of chlamydia and other sexually transmitted infections. To reach sexually active young men and women who are not accessing specialist sexual health services. To reduce the burden on secondary care services by diagnosing, treating infections and providing partner notification in the community. To increase opportunistic testing of asymptomatic patients consulting for unrelated conditions in general practice and community pharmacy. To increase early detection and treatment of chlamydia and therefore reducing transmission and complications associated with it. Expected Outcomes The expected outcomes of commissioning services in general practice and community pharmacy should be: 2.6 Achievement of specific local chlamydia testing targets for sexually active men and women under 25 years of age attending general practice and community pharmacy. Increasing the numbers of GPs and Pharmacists and other members of staff trained to deliver chlamydia testing, treatment and partner notification and the numbers undertaking regular continuous professional development (CPD). Increasing the number of completed tests provided by general practice and community pharmacies. Treatment outcomes that meet NCSP standards. Achievement of the local CSP Quality Assurance (QA) standards. Provision of all required mandatory data. Requiring a satisfactory system of audit to be in place Commissioning in line with NCSP core requirements Providers of any element of the chlamydia screening pathway, see Figure 1, are responsible for working to support the PCT in achieving population chlamydia screening coverage in under 25 year olds that meets the national targets. In 2009/10 this is 25% and in 2010/11 it will be 35%. Figure 1 Chlamydia Screening Pathway Ideally chlamydia testing, treatment and partner notification should form part of a wider bundle of sexual health care. For information on the cost effectiveness of different modes of testing and best yield please refer to the NCSP website1. 7 The geographical location and opening hours of services providing chlamydia screening should be informed by a local Sexual Health Needs Assessment and promote equitable access across the local health economy providing choice for people accessing services. The NCSP core requirements2 specify that providers of any element of chlamydia testing should: Identify a named chlamydia lead to communicate with the local chlamydia screening coordination. Utilise and prominently display relevant national and local sexual health and chlamydia screening materials. Ensure that staff are appropriately trained to deliver the programme. Offer user friendly, non judgemental, patient centred and confidential services in line with the ‘You’re Welcome’17 criteria. Provide people testing for chlamydia with an information leaflet as part of the consent process Adhere to national and local requirements regarding the management of under 18s. Be responsible for ensuring timely onward referral for those people who they are not able to manage. Be responsible for providing all mandatory data reporting to the local coordination. Be responsible for undertaking a satisfactory system of audit in line with the annual requirements to audit key performance indicators of the programme GP and Pharmacy Champions have been shown to effectively impact on uptake and screening rates in local health economies. For this reason the NCSP recommends that PCTs consider commissioning these roles. 2.7 Services that could be commissioned in General Practice PCTs may wish to commission General Practice to: 1. Solely distribute postal chlamydia screening kits 2. Provide on site chlamydia testing 3. Provide chlamydia testing, treatment and instigation of partner notification (for their own patients or a wider population) In all instances the service should be offered to sexually active under 25 year olds. Chlamydia screening kits All providers of postal chlamydia screening kits should deliver the services identified below: Advice on how to utilise the kit, how to return it for testing and what will happen following completion of the test including how people will be notified of results. Provide information signposting people to other sexual health services. Careful consideration should be given to any commissioning of services for under 16s due to the medico legal implications. 8 On site chlamydia testing All providers of on-site chlamydia testing should deliver the services identified below to people who are either requesting chlamydia testing or attending for routine consultations about other health concerns: People should be provided with information about chlamydia and other sexual health promotion including the benefits of testing, specimen collection, management of results and access to free treatment*. People declaring symptoms suggestive of sexual ill health should be risk assessed and managed appropriately. This may include referral to specialist sexual health services. If following risk assessment the person is identified as eligible for testing the appropriate electronic or paper form should be completed. Contact details should be requested and preferably two methods of contact recorded and verified. Samples and forms should be collected for analysis in a timely manner, as defined by local operational guidance. People should be signposted to other sexual health services as appropriate. Free condoms should be available. Commissioners should encourage general practice to develop mechanisms to identify under 25s registered in each practice who are appropriate for offering a chlamydia screen. Chlamydia testing, treatment and partner notification In addition to the services for chlamydia testing identified above, providers commissioned to provide treatment and instigate partner notification should deliver the services identified below: Manage the treatment of index cases*. Instigate partner notification. * People requiring treatment for STIs should receive this free of any prescription charge or, if this is not possible (e.g. where FP10 prescriptions are used) and the service user is not exempt, they should be offered access to another provider if they wish. Medication for the treatment of STIs should ideally be dispensed at the time of diagnosis20. 2.8 Services that could be commissioned in community pharmacies PCTs may wish to commission community pharmacies to: 1. Solely distribute postal chlamydia screening kits 9 2. Provide on site chlamydia testing 3. Provide chlamydia treatment and instigation of partner notification 4. Provide chlamydia testing, treatment and instigation of partner notification. In all instances the service should be offered to sexually active under 25 year olds. Chlamydia screening kits All providers of postal chlamydia screening kits should deliver the services identified below: Advice on how to utilise the kit, how to return it for testing and what will happen following completion of the test including how people will be notified of results. Provide information signposting people to other sexual health services. Careful consideration should be given to any commissioning of services for under 16s due to the medico legal implications. On site chlamydia testing All providers of on-site chlamydia testing should deliver the services identified below to people who are either requesting chlamydia testing or seeking pharmacist advice about other sexual health concerns or as part of a service to all customers in the appropriate age group: People should be provided with information about chlamydia and other sexual health promotion including the benefits of testing, specimen collection, management of results and access to free treatment*. People declaring symptoms suggestive of sexual ill health should be offered referral to an appropriate service. This may include referral to specialist sexual health services. If following risk assessment the person is identified as eligible for testing the appropriate electronic or paper form should be completed. Contact details should be requested and preferably two methods of contact recorded and verified. Samples and forms should be collected for analysis in a timely manner, as defined by local operational guidance. People should be signposted to other sexual health services as appropriate. Free condoms should be available. Commissioners should encourage community pharmacy to link chlamydia screening to existing services / sales in under 25s that are appropriate for offering a chlamydia screen eg emergency hormonal contraception, contraceptive pill prescriptions and condom sales. Chlamydia testing, treatment and partner notification 10 In addition to the services for chlamydia testing identified above, providers commissioned to provide treatment and instigate partner notification should deliver the services identified below: Manage the treatment of index cases*. Instigate partner notification. Chlamydia treatment only All providers of chlamydia treatment should deliver the services identified below: Manage the treatment of index cases*. In addition commissioners may wish to commission community pharmacies to manage people presenting with a contact slip for chlamydia or reporting to be a contact of chlamydia. In this case people should be provided with chlamydia testing as described above, given treatment for chlamydia and partner notification should be instigated. * People requiring treatment for STIs should receive this free of any prescription charge or, if this is not possible (e.g. where FP10 prescriptions are used) and the service user is not exempt, they should be offered access to another provider if they wish. Medication for the treatment of STIs should ideally be dispensed at the time of diagnosis20. 2.9 Care Pathways Commissioners should ensure that clear care pathways between services are established and articulated. Development of these could be supported by local sexual health networks20. Care pathways should focus on ensuring appropriate clinical management for people accessing services and support healthcare professionals in delivery of high quality care. They should be explicit, agreed and utilised by all providers of chlamydia screening and treatment. 2.10 Key Performance Indicators There are likely to be a number of key performance indicators (KPIs) that commissioners utilise to monitor the services they commission. The following three KPIs are considered by the NCSP as being core for services commissioned to provide the relevant elements of the chlamydia pathway: 1. Number of tests 2. Turnaround time from the date of the test to notification of results 3. Partner notification 4. Treatment rates KPI: Number of chlamydia tests Chlamydia tests: % of the target population each provider is responsible for screening. 11 (Standard: performance against specific agreed targets for each participating general practice based on the practice population of 15-24 year olds.; performance against specific agreed targets for each participating community pharmacy that are linked to another PCT funded sexual health service). KPI: Turnaround times from the date of test to notification of results Turnaround times: time from date of test to notification of result by provider, laboratory or Chlamydia Screening Office as appropriate. (Standard: 90% of results notified within 10 working days of test taken). KPI: Partner notification Partner notification: rate of partner notification for chlamydia and gonorrhoea by provider. (Standard: at least 0.4 contacts per index case in large conurbations or 0.6 contacts elsewhere within four weeks). KPI: Treatment rates Treatment rates: % of chlamydia positive index cases receiving treatment. (Standard: 95% of index cases confirmed to have received treatment). 12 References 1 General information regarding the NCSP programme is available at: http://www.chlamydiascreening.nhs.uk 2 NCSP core requirements available at: http://www.chlamydiascreening.nhs.uk/ps/sharing/general.html 3 Information regarding chlamydia screening in general http://www.chlamydiascreening.nhs.uk/ps/sharing/general.html 4 Information regarding Chlamydia screening in http://www.chlamydiascreening.nhs.uk/ps/sharing/pharm.html 5 Vital Signs guidance available at: www.chlamydiascreening.nhs.uk 6 Quick wins and sustainable services: Hitting the target without missing the point. NCSP, September 2008 7 Salisbury C, Macleod J, Egger M, et al. Opportunistic and systematic screening for chlamydia: a study of consultations by young adults in general practice. Br J Gen Pract. 2006;56(523):99–103 8 Trends in the Consultation Rates in General Practice 1995 to 2007. Analysis of the QRESEARCH database. 2008. QRESEARCH and The Health and Social Care Information Centre 9 White Paper Pharmacy in England: building on strengths – delivering the future. DH. April 2008. practice pharmacies is is available available at: at: 10 Information regarding GMS/PMS/APMS contracts available at: http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/index.htm 11 Information regarding the NHS Community Pharmacy Contractual Framework available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_40 91867 12 Further information on the NCSP costings review is available at: www.chlamydiascreening.nhs.uk 13 Department of Health. NHS Community Pharmacy Contractual Framework. Enhanced Service – Chlamydia Screening & Treatment, 2008, updated in 2010, available at : http://www.psnc.org.uk/enhanced 14 The National Strategy for Sexual Health & HIV, DH, 2001 15 Next Stage Review, DH, 2008 16 Our Health, Our Care, Our Say, DH, 2006 17 You’re Welcome quality criteria: Making health services young people friendly. DH, 2005. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_41215 62 18 Progress and priorities: working together for high quality sexual health. IAG/ MedFASH, 2008. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_086 525.pdf 19 Operating Framework 2009/10. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_09144 5 20 Standards for the Management of STIs. 2009. Available at: http://www.medfash.org.uk 13
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