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