A presentation on Sexual Health Services in Birmingham that was presented to the Public Health Transition Workshop on the 3rd July.

1. Sex and the 2nd City
Liz Altay
Consultant in Public Health
David Walker
Head of Sexual Health and Teenage Pregnancy
Commissioning

2. Sexual Health
• Sexual health and HIV a major public
health issue
• UK has highest rates of poor sexual health
in Europe
• Parts of Birmingham very high rates
• Increasing STIs, HIV & terminations
• Inequalities in sexual health
• Preventable

3. HIV and STI in Birmingham
Diagnosis rates of the five main STI diagnoses (GUM only) and HIV* in Birmingham residents,
1996-2011
A B
300 Chlamydia 18
Gonorrhoea
16 Syphilis
Genital Herpes Simplex
250 New HIV diagnoses
Genital Warts
Rate per 100,000 population
Rate per 100,000 population
14
200 12
10
150
8
100 6
4
50
2
0 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Episode Year Episode Year
* New HIV diagnoses data for 2011 not yet available
Please note that the above data does not include non-GUM chlamydia screening results
Source: HPA – West Midlands STI Surveillance Project; New HIV diagnoses data to end June 2011
Data provided by HPA West Midlands Regional Epidemiology Unit

4. Acute STI diagnosis rates (GUM only) in Birmingham, West Midlands and England,
2009-2011
1400
2009 2010 2011
Rate per 100,000 population
1200
1000
800
600
400
200
0
HoB Sth Bham BEN Birmingham West Mids England
Please note that the above data does not include non-GUM chlamydia screening results
Source: HPA – Genitourinary Medicine Clinic Activity Dataset (GUMCAD)
Data provided by HPA West Midlands Regional Epidemiology Unit

5. Rates of acute STI diagnoses in Birmingham residents (GUM only) by age group and gender,
January – December 2011
3500
Female Male
Rate per 100,000 population
3000
2500
2000
1500
1000
500
0
<15 15-19 20-24 25-34 35-44 45+
Age at start of episode
Please note that the above data does not include non-GUM chlamydia screening results
Source: Genitourinary Medicine Clinic Activity Dataset (GUMCAD)

6. Counts and rates of acute STI diagnoses in Birmingham residents (GUM only) by ethnic group and
gender, January – December 2011
2500 4500
Female Male
Rate per 100,000 population
Female Male
4000
Count of diagnoses
2000 3500
3000
1500
2500
2000
1000
1500
500 1000
500
0 0
Asian Black Mixed Other White Not Asian Black Mixed Other White
specified
Ethnic Group Ethnic Group
Source: Genitourinary Medicine Clinic Activity Dataset (GUMCAD)
Data provided by HPA West Midlands Regional Epidemiology Unit

7. Rates of acute STI diagnoses in West Midlands residents (GUM only) by PCT (graph) and local
authority (map) of residence, January – December 2011
1400
2010 2011
1200
Rate per 100,000 population
1000
800
600
400
200
0
© Crown copyright and database right 2012. All rights reserved. Ordnance Survey Licence number 100016969/100022432
Source: Genitourinary Medicine Clinic Activity Dataset (GUMCAD)
Data provided by HPA West Midlands Regional Epidemiology Unit
Date Prepared: 02/07/2012

8. Rates of acute STI diagnoses in Birmingham (GUM only) by ward of residence,
January – December 2011
© Crown copyright and database right 2012.
All rights reserved. Ordnance Survey
Licence number 100016969/100022432
Source: Genitourinary Medicine Clinic Activity Dataset (GUMCAD)
Data provided by HPA West Midlands Regional Epidemiology Unit

9. Diagnosed HIV infected patients accessing care, West Midlands, 2010
Persons with diagnosed HIV accessing care
0 200 400 600 800 1000 1200 1400 1600
Birmingham
Coventry
Sandwell
Wolverhampton
Warwickshire
Stoke On Trent
South Staffordshire
Walsall
Worcestershire
Dudley
Shropshire County
North Staffordshire
Solihull
Telford And Wrekin
Herefordshire
Source: HPA –Survey of Prevalent HIV Infections Diagnosed (SOPHID)
Data provided by HPA West Midlands Regional Epidemiology Unit Date Prepared: 02/07/2012

10. Prevalence of diagnosed HIV infection in adults (15-59 years), Birmingham, 2010
© Crown copyright and database right 2012.
All rights reserved. Ordnance Survey
Licence number 100016969/100022432
Source: HPA – Survey of Prevalent HIV Infections Diagnosed (SOPHID)
Data provided by HPA West Midlands Regional Epidemiology Unit

11. Diagnosed HIV infected patients accessing care by deprivation quintile, Birmingham, 2006 and 2010
80%
2006 2010
Proportion of patients accessing care
70%
60%
50%
40%
30%
20%
10%
0%
1 2 3 4 5
Most deprived Deprivation Quintile Least deprived
Source: HPA –Survey of Prevalent HIV Infections Diagnosed (SOPHID)
Data provided by HPA West Midlands Regional Epidemiology Unit

12. Abortions
All Age Abortion Rate 2010 : Source NCHOD
and Local TOPS data Source BSol BI
30
25
20
15
Crude Rate per 1,000 Women
aged 15-44
10
5
0
ENGLAND AND WALES
ENGLAND
Heart Of Birmingham Teaching
WEST MIDLANDS
South Birmingham PCT
Birmingham East and North PCT
PCT
Birmingham local moving average 2008-10

13. Abortion rate per 1,000 population aged 18-44 by PCT
2010

14. 500
0
1000
1500
2000
2500
3000
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Under 18
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
18-24 yrs old
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
For the 12 months ending
Jul-10
25-34 yrs old
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
BPAS and Calthorpe activity trends - rolling 12 month totals
Jan-11
35 yrs old +
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Abortions (Birmingham)
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12

16. Teenage Conception Rate per 1000 Females 15-17 years
Teenage Conception Rates
Birmingham West Midlands England 2010 Target
70.0
60.0
Under 18 conception rate per 1000
50.0
40.0
30.0
20.0
10.0
0.0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Source: Birmingham and Solihull Business Intelligence

17. Number of Teenage Conceptions per 1000 Population Females aged 15-17
between April 2007 and March 2010 by Ward
Source: Bham and Solihull Business Intelligence 2012

18. Teenage Pregnancy Chlamydia Screening
Services Programme
Termination of Pregnancy
Services
Sexual Health Promotion
Services
Young Peoples Genito-Uriniary
Services Services
Specialist HIV Treatments
Reproductive Sexual Health
Services
Third Sector HIV Services

19. Level 3 – Investigation and management of complex STI’s, HIV complex
contraception needs due to other illness. Termination of pregnancies.
Vasectomy.
Specialist Sexual Health Promotion
Level 2 – Psychosexual therapies
Level 2 – Symptomatic & asymptomatic STI’s. Partner notification. LARC
provision
Level 2 – services also provide services as outlined in level 1
Level 1 – Oral contraception. Condoms. EHC. Sexual Health Promotion.
Abortion referral. Vasectomy referral. Full sexual health history and
assessment. Screening of asymptomatics for chlamydia and gonorrhoea
(GC+ve ref to level2. HIV Testing / ongoing shared care with level 3

20. Example of integrated service delivery
Level 3: investigation and management of complex STIs, HIV complex
contraception needs due to other illness. Termination of Pregnancies.
Vasectomy.
Specialised Sexual Health Promotion
Level 2 - symptomatic & asymptomatic STIs. Partner notification. LARC
provision
Level 2 services also provide services as outlined in level 1
. Psychosexual therapies.
Level 1 – Oral contraception. Condoms. EHC. Sexual health promotion.
Abortion referral. Vasectomy referral. Full sexual health history and
assessment. Screening of asymptomatics for chlamydia and gonorrhoea (GC
+ve ref to level 2). HIV testing/ on going shared care with level 3
NB All services to provide SH promotion.

22. Sexual Health in the 2nd City - What has been
achieved?
•10 year national strategy – sexual health , teenage pregnancy, HIV
Commissioning – understanding need + local SH strategy
•New programmes /partnerships – Teenage pregnancy
•NHS Performance framework – KPIs : access to terminations
, teenage conceptions and chlamydia
•Real growth in range , type , quality of service provision
•Increased funding – from £8.78 million [ 2006 ] to £ 20 million plus]
•Real Improvements in sexual health outcomes

23. Sexual Health in the 2nd City - What has been
achieved?
25.7% reduction in Teenage conception rates December 1998 and June
2012 cf West Midlands (19.4%) : England (20.3]
Chlamydia screening coverage [ 15 – 24 yrs ] 29 %- 33% cf national average
- 25.2 %
50% decline in Gonorrhea rates - 10 years

24. Sexual Health in the 2nd City - Challenges :
• Inequalities in sexual health persist
• Distribution of services - not rational /needs led
•Quality and range of primary care services – v .variable
•Balance of investment [ GUM ] – “downstream “ not prevention
•Service provision – separate , parallel , fragmented

25. Sexual Health in the 2nd City – Determinants of
sexual health
• Social deprivation
• Ethnicity
• Migration
• Culture
• Service provision + access
• Neighbourhoods

26. Opportunities:
Focus on Social Determinants of Health
Move away from ‘Deficit’ model of delivery to an ‘Asset ‘ model of
delivery
•Deficit model – focuses on failure of communities to avoid
disease
•Asset model - focuses on the potential to create and sustain
health

27. Opportunities:
Focus on Social Determinants of Health
How ?
•As an employer
•Through the services commissioned and delivered
•Through regulatory powers
•Through community leadership
•Through localism
•Any others?

28. Sexual Health System
• Health Improvement (Public Health lead)
• Strategy/Policy
• Reducing SH inequalities
• Sexual Health promotion/prevention
• Health Protection (HPA lead)
• Surveillance
• Epidemiology
• Outbreaks
• Sexual Health Service Improvement (Public Health/NHS Cluster)
• Commissioning effective services
• Audit & evaluation
• Clinical Governance

29. Current commissioned services
Level 3 Genito-urinary medicine (GUM) Specialist
HIV treatment and care services
Complex contraceptive services
(provided by acute trust) Abortion
services – acute
Level 2 Integrated, community based trusts and
contraceptive and sexual health Independent
services x 2 Clinics Sector.
Brook (Young People Focused)
GP enhanced, open access services Psychosexual
– 2 clinics service
GP provision of coil and implants
Level 1 GMS/PMS GP services Sexual Assault
Chlamydia screening programme Referral Centre
Community pharmacy services (SARC)
Health promotion
Teenage Pregnancy programmes

30. Sexual Health Responsibilities
• LAs will be mandated to commission open access STI testing &
treatment and contraception services for all persons present in their
area. LAs will commission needs-led sexual health services for its
population. The commissioning responsibility will involve holding
the ring for an integrated sexual health system, core functions
include:
– comprehensive needs assessment;
– strategy development
– sexual health promotion, particularly with high risk groups
– health protection in the form of surveillance, epidemiology and the
management of outbreaks;
– provision of partner notification;
– targeted services, including outreach work for high risk groups;
– procuring high quality accessible integrated sexual health services;
– workforce planning in partnership with training consortia;
– monitoring sexual health outcomes.

31. PHOF Outcomes
• Chlamydia diagnoses (15-24 year olds)
• Reduction in people presenting with HIV at a
late stage of infection
• Reduction in teenage conceptions in under
18’s
• Indirectly related outcomes:
• ante-natal HIV screening
• Violent crime (including sexual violence)
• Employment for those with a long-term health
condition including those living with HIV

32. Local Authorities will commission Clinical Commissioning Groups NHS Commissioning Board will
will commission commission
Comprehensive sexual health Fully integrated and comprehensive Contraception provided as an
services, including: termination of pregnancy services – additional service under the GP
[but there will be a further contract
Contraception, including LESs consultation about the best
(implants) and NESs commissioning arrangements in the HIV treatment and care [although
(intrauterine contraception) – longer term] work is continuing to determine
but excluding contraception whether CCGs should commission
provided as an additional Sterilisation some elements of the pathway]
service under the GP contract)
STI testing and treatment, Vasectomy Promotion of opportunistic testing
including post-exposure and treatment for STIs and patient
prophylaxis after sexual requested testing by GPs
exposure, chlamydia screening
as part of the National
Chlamydia Screening Sexual Assault Referral Centres
Programme and HIV testing
Sexual health aspects of
psychosexual counselling
Any sexual health specialist
services, including young
people's sexual health and
teenage pregnancy services,
outreach, HIV prevention and
sexual health promotion work,
services in schools, colleges
and pharmacies

33. 1st April 2013
Level 3 Genito-urinary medicine (acute trust) Specialist
HIV treatment and care services
Complex contraceptive services
(provided by acute trust) Abortion services
Level 2 Integrated, community based – Acute trusts and
contraceptive and sexual health Independent
services: Sector
Brook
GP enhanced, open access services – 2 Psychosexual
clinics service
GP provision of coil and implants
Sexual Assault
Level 1 GMS/PMS GP services
Referral Centre
Chlamydia screening programme (SARC)
Community pharmacy services
Health promotion
Teenage Pregnancy programmes

34. Sexual Health Commissioning Options
Service Provider Current LAs Contract Clinical Commissioner Contract
Commissioner Support Governance post April 13 Support
April 13
GUM NHS Trust BPH Birmingham,Solihull BSol NHS Cluster BSol NHS Cluster PH in Local CSS
Sandwell,Dudley Authority
Walsall
HIV Treatment NHS Trust NHS Specialised West Midlands NHS Specialised NHS Specialised NHS CB NHSCB/CSS
commissioner commissioner commissioner withPH support
via core offer
Integrated Sexual NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSS
Health Services Authority
rd
Brook (Young People) 3 sector BPH Birmingham & BPH BSol NHS Cluster PH in Local LA
Solihull Authority
Chlamydia Screening NHS Trust BPH Birmingham & BSol NHS Cluster BSol NHS Cluster PH in Local CSS
(under 25s) Solihull Authority
Reproductive Sexual NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSS
Health Services Authority
(Contraception)
Sexual Health NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSS
Promotion/Training Authority
rd
Termination Services 3 sector BPH Birmingham BPH BSol NHS Cluster CCGs with PH CSS
Solihull support via core
Shropshire offer
Enhanced primary care GPs BPH Birmingham Cluster Primary BSol NHS Cluster PH in Local NHS CB
services Pharmacies Care Authority
Commissioners (via NHS CB?)
rd
HIV Prevention Services 3 sector BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local LA
Authority
Psycho-sexual NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local CSS
counselling Authority
Teenage Pregnancy NHS Trust BPH Birmingham BSol NHS Cluster BSol NHS Cluster PH in Local LA & CSS
programmes/services BCC Primary Care Authority
Pharmacies BPH
rd
3 sector
SARC To be tendered BPH Birmingham,Solihull BSol NHS Cluster BSol NHS Cluster NHS CB NHSCB/CSS
Walsall,Wolvs,Dudley with PH support

35. Proposal
• Policy/Strategy – PH core team (LA) & PHE
• Needs assessment – PH core team (LA)
• Sexual Health Improvement/prevention activity – PH core team (LA)
• Sexual Health inequalities – PH core team (LA)
• Health protection (surveillance, outbreaks, epidemiology)– PHE with
oversight from DPH through Birmingham HP Forum
• Strategic commissioning of sexual health services – PH core team
– Contract Support for NHS Services – CSS (including Clinical Governance)
– Contract Support for non NHS Services – LA (including clinical governance)
•Strategic commissioning advice and support to NHS CB and CCGs –
PH core team (LA) through “core offer”