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Service Specification for the Targeted Primary Care Sexual Health Service Provided in GP practices.IntroductionThis service specification will contribute to the overall delivery of the local Sexual Health System. The Provider delivering these services will have close working relationships with other GPs, pharmacies and the local Integrated Sexual Health Service (YorSexual Health). They will have a good understanding of other provision in their area. They will know who to contact within YorSexual Health for specialist support and advice, and to access local training. The services will be commissioned as one basket of services. These services will be provided in addition to contraceptive services GP’S Practices already deliver as part of their General Medical Services (or PMS) contract managed by NHS England.Outline of the targeted primary care sexual health services provided in GP practicesThe targeted primary care sexual health services described in this Specification are commissioned as a ‘basket’ of services from the Provider. This means that the Provider is contracted to deliver all the services in the basket – they cannot opt to deliver individual elements. The services to be provided are:LARC (Long – acting reversible contraception) service to women of all ages – subdermal implant (SDI) or intra-uterine system / intrauterine device (IUS/IUD)Chlamydia screening service to under 25 year olds (as part of the National Chlamydia Screening Programme)Free condoms to under 25 year oldsProvision of sexual health information to service usersService objectivesThe specific objectives of the service that the Provider will deliver are:To increase the availability of LARC through primary care and contribute to improved uptake rates of LARCTo ensure the fitting of post-coital IUD for emergency contraception is more widely available To improve access to ‘self-administered’ chlamydia screening kits to under 25 year olds (for under 16’s see safeguarding section of this specification) and increase the number of test samples returned for analysis. To encourage partner notification, screening and treatment where patients have a positive result. To promote the use of condoms and encourage safer sex practiceTo promote the Double Dutch method of using two forms of contraception against pregnancy and STIs.To raise awareness of sexual health issues and facilitate access to other sexual health and related services.This ‘basket of services’ delivered by the Provider will contribute to delivery of the following indicators which are monitored by the Commissioner to measure the effectiveness of delivery of the local sexual health system.The rate of sexually transmitted infections (STIs) diagnoses in clinic attendeesThe rate of STIs diagnoses in young people attending clinicsThe chlamydia diagnostic rate for those aged 15-24 The rate of late HIV diagnosesThe rate of under 18 conceptionsThe number of abortions The number of under 18 abortionsEvidence Base4.1LARCGuidance from NICE has found that, while all methods of contraception are effective, long-acting reversible contraception (“LARC”) methods such as contraceptive injections, implants, the intra-uterine system or the intrauterine device (“IUD”) are much more effective at preventing pregnancy than other hormonal methods, and are much more effective than condoms. However, a condom should also always be used to protect against STIs.4.2Chlamydia screening for under 25 year olds (as part of the National Chlamydia Screening Programme (NCSP))Chlamydia is the most common bacterial sexually transmitted infection, with sexually active young people at highest risk. As chlamydia often has no symptoms and can have serious health consequences (e.g. pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility) opportunistic screening remains an essential element of good quality services for young people. Provision of chlamydia screening in primary care provides the opportunity for young people not necessarily in contact with sexual health services to receive testing. The aim of this service in primary care is to increase the uptake of screening and treatment (if appropriate) for Chlamydia by young people and thus help contribute to a reduction in the prevalence of the infection and its medical complications. Around 75% of young adults visit their GP every year, providing an ideal opportunity to offer an annual chlamydia screen. Guidance states that for this age group tests are advised annually; on change of partner; or 3 months after chlamydia treatment.4.3Free condoms to under 25 year oldsCondoms can be expensive and, when buying them, young people are often embarrassed to ask for advice. In this context the distribution of condoms to young people is an effective and practical way of preventing further unplanned pregnancies and sexual infections.Providing condoms can also provide useful opportunities for sexual health promotion in safe and informal settings.Used consistently and correctly, male condoms are up to 98% effective in preventing pregnancy and female condoms up to 95% effective. In general evidence supports the use of condoms to reduce the risk of STI transmission; however, even with correct and consistent use, transmission may occur. 4.4Provision of sexual health informationIt is important that young people and adults are able to make informed and responsible decisions, understand issues around consent and the benefits of stable relationships and are aware of the risk of unprotected sex. It is important that women are able to access the full range of contraception to avoid unwanted pregnancy. Description of servicesThe specific requirements which shall be delivered by the Provider are:5.1LARCThe Provider will ensure that all women considering LARC methods receive detailed information – both verbal and written – that will enable them to choose a method and use it effectively. This information should take into consideration their individual needs and should include:Information about all methods of contraceptionContraceptive efficacyDuration of useRisks and possible side effectsThe procedure for initiation and removal/discontinuation The Provider will undertake a medical history – including relevant contraceptive and sexual history as part of the routine assessment of medical eligibility for individual contraceptive methods. The Provider will assess individual risk for sexually transmitted infections and advise testing if appropriate. The Provider will administer the service users chosen LARC method. This must only be one of the contraceptive drugs or devices as detailed in appendix 1. If the service user chooses a LARC method the Provider does not provide the service user will be sign-posted to a nearby Primary Care Service or YorSexual Health for that procedure.If a gap in service is identified, opportunities for developing inter-practice referrals will be explored, with support from the Commissioner. In this situation it will be important for each practice to agree appropriate governance arrangements between them e.g. access to full patients notes, recording and reporting of intervention details, follow-up procedures etc. The practice providing the service would claim for all activity and would have their retainer payment adjusted accordingly. The Provider will ensure the provision of adequate equipment to deliver this service (standard IUD/IUS equipment is required for IUD/IUS/SDI fitting). This includes an appropriate room fitted with an accessible couch, lighting and resuscitation equipment. An appropriately trained Health Care Professional also needs to be present to support the Service User and assist the doctor during the procedure.The Provider will advise an interim method of contraception at first appointment if required.The Provider will promote safer sex as part of their contraceptive advice and if appropriate offer free condoms (as per section 5.3 below).The Provider will check, monitor and remove IUD/IUS and progestogen only sub-dermal implants (SDI) as detailed below:3-6 week IUD/IUS follow ups after insertion (to check threads, exclude perforation, and exclude expulsion or presence of any pelvic tenderness). Service users should return in time for removal, otherwise no further follow-ups are necessary.Service users with progestogen-only sub-dermal implants should return in time for removal, otherwise no further follow-up necessary.Additional follow-ups only where necessary: Women should be encouraged to return only if problems occur.If the Provider is unable to offer a LARC appointment within 4 weeks of the patient requesting a fitting, the Provider will refer the service user to YorSexual Health.The Provider will also provide insertions of a copper IUD (up to 5 days after presumed ovulation) as a method of emergency post-coital contraceptive. The Provider will ensure an appointment is available within 24 hours (excluding weekends). In order to ensure rapid access it is acceptable for the Provider to refer service users to a nearby Primary Care Service for this procedure e.g. to cover holiday periods etc.Where there is a need for ultrasound scanning for the location of deeply placed impalpable implants the Provider can refer service users to YorSexual Health. In order to get a timely appointment, ring the booking line on 01904 721111 and select option 2.Where there is a need for ultrasound scanning for the location of intrauterine devices with threads not visible on pelvic examination, the Provider can refer service users to YorSexual Health. In order to get a timely appointment, ring the booking line on 01904 721111 and select option 2. 5.2Chlamydia screening service to under 25 year olds (as part of NCSP)The Provider will work with YorSexual Health to promote and supply free chlamydia testing kits to all under 25’s attending the practice for any sexual health related matter (e.g. contraception). Test kits will be provided by YorSexual Health, along with specimen pots and patient information. For ordering information see Provider will encourage service users to provide a sample at the time of their attendance at surgery, and will if necessary give assistance with completion of the form, or use the electronic downloadable forms available. The Provider will offer a free chlamydia test to all under 25 year olds who are being fitted with a LARC method.The Provider will inform the service user about how to use the kit, what happens afterwards, i.e. how results are provided, what will happen if a positive result is obtained (treatment and partner notification services).The Provider will inform the service user that YorSexual Health will provide results to service users, discuss treatment options, and manage the partner notification service. The Provider will inform the service user that they can choose to be treated either through the Provider or through YorSexual Health; and will make them aware that if treated through the Provider they will have to pay the FP10 prescription charge if they are not exempt whilst treatment through YorSexual Health is free of charge. If the Provider is providing the treatment it will include verbal and written follow-up advice, based on guidance from YorSexual Health.5.3Free Condom serviceThe Provider will sign up to and implement the free condom service that is managed and resourced by YorSexual Health (complying with the governance and training requirements stipulated by YorSexual Health). For further details see here Provider will supply condoms and lubricants to under 25s (using the ordering process run by YorSexual Health) together with supplying information about sexual health and contraception and local services. The Provider will comply with monitoring systems, standards, policies and procedures as designated by YorSexual Health to ensure that all staff involved in the scheme on behalf of the Provider comply with the schemes policy around safeguarding and issuing contraception, particularly to under 16 year olds.5.4Provision of sexual health informationThe Provider will provide a range of evidence based sexual health information tailored to meet the needs of different age groups on:How to prevent and/or get tested for STIs and how to prevent unwanted pregnanciesAll methods of contraception including LARCs,How to get and use emergency contraceptionOther reproductive issues and concernsWhere to access further information and guidance about sexual health services.The Provider will ensure the full range of sexual health promotion information is available in the Provider’s premises in literature stands/displays as well as providing appropriate information as part of a sexual health consultation.The Provider will advertise the full range of sexual health services it offers on its own website and the YorSexual Health website, and have links to NHS Choices.The Provider will provide information in a range of formats and mediums to meet language and literacy needs.,The Provider will engage in local targeted public health campaigns led by YorSexual Health to promote key sexual health messages and services, for example World Aids Day, HIV Testing Week.5.5Other public health servicesThe provider will ensure patients’ needs for other public health services delivered by the Practice are identified and addressed – e.g. drug misuse, smoking cessation, alcohol?misuse. The Provider will encourage patients eligible for the NHS Health Check to engage with this provision. ?? Service DeliveryThe Provider will be expected to deliver services taking into account the following elements:Access Eligibility criteriaExclusion criteriaReferral pathwaysMarketing & publicityEnvironment & premisesData managementWorkforceClinical governance arrangementsSafeguardingConfidentiality & consentService User feedbackSupport from YorSexual HealthQuality standardsAccess The Provider will ensure the Service will be available to non-registered (known as temporary residents) and registered patients. The Provider will ensure the basket of services is available to the age groups as defined in this Specification.The Provider must classify post-coital IUD insertions as emergency appointments, ensuring rapid access to appointments. It is acceptable for GP Alliances to work together to ensure rapid access.The Provider will ensure that reasonable effort is made to provide translating services for clients whose first language is not English.6.2 Eligibility CriteriaThe Provider shall operate an open access policy regardless of residence of the Service User.LARC should be made available to women of all ages who are registered and non- registered service users.Chlamydia Screening should be made available to all registered and non-registered users aged under 25 years.Free condoms should be available to all registered and non-registered service users who are under 25 years.6.3 Exclusion CriteriaServices not funded:Use of LNG-IUS for the management of heavy menstrual bleeding (HMB) or hormone replacement therapy (HRT) is out of scope of this service. (If this changes due to any future agreements made between the CCGs and NYCC, contract variations will be issued to the relevant practices). Refusal of service provision:The Provider has the right to refuse service provision in the following circumstances:to users who are unsuitable for treatment under the conditions of this service Specificationfor any unreasonable behaviour deemed unacceptable to the Provider, it’s Staff, or the named professional clinically responsible for the care of the service user6.4Referral pathwaysThe Provider will work within recognised referral pathways for both receiving and making onward referrals to other services, including:YorSexual HealthTermination servicesMaternity servicesSexual Assault Referral Centres (SARCs)HIV Specialist Services GynaecologyUrologyA&EGP’s Local vasectomy servicesPharmacistsHealthy Child Programme teamSubstance misuse servicesMental health servicesOther services within the sexual health system6.5Marketing and PublicityThe Provider will advertise the full range of sexual health services it offers on its own website and the YorSexual Health website, as well as links to NHS Choices.6.6Environment and premisesThe Provider will adhere to good practice guidance around premises, for example:Essential standards of quality and safety; CQC 2010 guidance - Out-patient care. Health Building Note 12-01: Consulting, examination and treatment facilities. Supplement A: Sexual and reproductive health clinics. London: The Stationary Office. managementThe Provider must: ensure all data management systems comply with Data Protection and Caldicott requirementsgenerate a monthly monitoring report of service user attendances and interventions delivered for payment and performance purposes to be submitted via a system provided by the Commissioner maintain full patient records including for non-registered patients.6.8WorkforceThe workforce providing the service under this Specification, on behalf of the Provider, will have the necessary skills to deliver the basket of services and comply with all appropriate standards, for example the standard as set out by the Faculty of Sexual and Reproductive Healthcare (FSRH). LARC All GPs and nurses working on behalf of the Provider will be trained to the competencies and training programmes agreed by all the relevant education bodies including RCGP, RCOG, FSRH, RCN.All GPs and nurses delivering the service should hold LoC IUT (Letter of Competence for Intrauterine Techniques) and/or LoC SDI (Letter of Competence for Sub-Dermal Implants). Details on training can be found here then click on Qualify, and here then click on Qualify.For experienced practitioners there is a fast-track route also detailed in the above links.In order to maintain competence each individual delivering the service must provide the following per year:For LoC IUT, a minimum of 12 insertions - if provided, fittings for heavy menstrual bleeding can be counted towards this. (Note - a minimum of 12 insertions with at least two different types of IUT method are required for recertification every five years).For LoC SDI, a minimum of six SDI procedures, including at least one insertion and one removal.Practices will need to ensure that each of their practitioners delivering this service can meet these requirements each year. There will be a requirement to report this information in the enrolment template for LARC within Outcomes4Health.All staff must complete recertification every 5 years – details can be found here screening service to under 25 year olds The Provider will ensure their staff are familiar with the chlamydia screening programme information provided by YorSexual Health (detailed here ). This will ensure staff are appropriately equipped to deliver a chlamydia screening service, in accordance with the latest NCSP standards.Condom distribution serviceThe Provider must participate in the free training as stipulated by YorSexual Health to ensure that staff meet the requirements set by the service.6.9Clinical governance arrangementsThe Provider must have a nominated lead for clinical governance and have a named lead for sexual health (this may be the same person) and will link with YorSexual Health.The Provider must be registered with the Care Quality Commission (CQC) as providers of ‘regulated activities.’The Provider must comply with current national regulations and directions on confidentiality and disclosure of information on sexual health and then follow the new statutory Code of Practice on Confidentiality once published.The Provider must comply with Caldicott requirements on information governance.The Provider must have robust systems in place for managing incidents and comply with policies and procedures set out by the Commissioner for reporting incidents including serious untoward incidents.The premises in which examinations and procedures are performed must comply with relevant national guidance and all local infection control and Health and Safety policies.6.10 SafeguardingThe safety and wellbeing of children, young people and vulnerable adults is paramount. The Provider must ensure that all Staff (including administrative staff) are compliant with child protection and Children and Adult Safeguarding Policies. For example, the Provider must ensure all Staff are aware of and trained to a level appropriate to their role in accordance with the Safeguarding Children and Young People: roles and competences for health care staff Intercollegiate Document, March 2014 and abide by national and local guidance and legislation on safeguarding (children and adults). Staff must be competent in joint working with safeguarding teams and Designated Health Professionals, i.e. Designated Nurse and Designated Doctor for Child Protection/Safeguarding Children (see link for further information regarding Designated Health Professionals).The Provider shall consider the government’s guidance as set out in the document Working Together to Safeguard Children: A guide to interagency working to safeguard and promote the welfare of children (DfE March 2013). The Provider shall comply with the North Yorkshire Safeguarding Adults and Safeguarding Children Board’s policies and procedures including best practice guidance with regard to child sexual exploitation, sexual abuse and neglect. These can be found at the following webpage links: North Yorkshire Safeguarding Children Board (safeguardingchildren.co.uk) North Yorkshire Adults Safeguarding Board ()When working with Service Users under the age of 16, the Provider shall adhere to the Department of Health’s guidance document Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health (DH 2004). The Provider shall comply with their specific responsibilities and safeguarding protocols relating to young people aged 13-15 years and for those under the age of 13 years. The Provider shall have robust child protection and adult safeguarding policies and procedures. The Provider shall have a named lead for safeguarding covering both children and adults. The Provider shall ensure compliance with the Mental Capacity Act where clinicians have contact with young people aged 16-17, those with learning difficulties or where there is impairment in decision making.DBS checksDBS checks are part of CQC registration requirements for GP practices and their staff. The level of that check depends on the roles and responsibilities and the type of contact the person will have with vulnerable groups. The Provider is responsible for determining which level of DBS check staff are eligible for.6.11Confidentiality and consentThe Provider will provide service users with privacy and ensure that consultations are confidential. People have a right to confidentiality regardless of where they access services from for reproductive and sexual health issues. The Provider shall provide clear information to their service users explaining confidentiality, and the reasons why confidentiality may be broken. The Provider shall obtain consent for information to be shared with health professionals for the purposes of treatment and prevention. Services must be compliant with the FSRH Standard Statement on Confidentiality and be young people friendly (e.g. “You’re Welcome”). The legal framework on consent, confidentiality and safeguarding (child protection) is covered by the General Medical Council publication, 0–18 Years: Guidance for All Doctors (2007)6.12 Service User FeedbackThe Provider will conduct regular service user engagement taking account of You’re Welcome Standards to ensure services are responsive to needs, improve clinical outcomes and patient experience, and support good governance.The Provider shall have in place a well-publicised feedback and complaints procedure which includes quality standards related to how complaints are dealt with and responded to.6.13Support from the Integrated Sexual Health Service (YorSexual Health)The Provider can expect clinical leadership from YorSexual Health and will receive the following:Access to level 1 & 2 training provided by YorSexual Health as part of their free annual training programme. The training programme does not include backfill costs.Free condoms and chlamydia test kits for under 25s.A named local clinical sexual health lead who will provide support and respond to any queries related to the delivery of sexual health services.The Provider is required to actively engage with YorSexual Health, and be part of the wider local sexual health system as well as promoting their local services.6.14Quality and service delivery standardsThis Service shall be delivered in accordance with the following:Service Standards for Sexual and Reproductive Healthcare (FSRH 2013)A Quality Standard for Contraceptive Services (FSRH, 2014)Service Standards for Consultations in Sexual and reproductive Health (FSRH, 2015)CEU Guidance - Intrauterine Contraception (FSRH, 2015)PH51 Contraceptive services with a focus on young people up to the age of 25: guidance (NICE, 2014)CEU Guidance – Emergency Contraception (FSRH 2012)UK National Guideline on Safer Sex Advice (BASHH & BHIVA 2012)National Chlamydia Screening Programme Standards (7th Edition 2014)UK Standards for Microbiology Investigations Chlamydia trachomatis Infection – Testing by Nucleic Acid Amplification Tests (NAATs), Public Health England (2014) .uk/webc/HPAwebFile/HPAweb_C/1317131315215Chlamydia Testing Activity Dataset (CTAD): Commissioning guidance; 2015 update (PHE, 2015)Hepatitis B and C: Ways to promote and offer testing to people at increased risk of infection. NICE Public Health Guidance 43 (NICE 2012)The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7 (RCOG 2011)Progress and Priorities - Working Together for High Quality Sexual Health (MEDFASH 2008)CG30 Long-acting reversible contraception (NICE 2005)Recommended Standards for Sexual Health Services (MEDFASH 2005)Safeguarding children and young people: roles and competences for health care staff Intercollegiate Document March 2014 (RCPCH, 2014)Relevant UK clinical guidance covering the specialities of Sexual and Reproductive Healthcare and Genitourinary Medicine can be found at and . The Provider shall ensure the service reflects updates in guidance and recommendations as and when produced. FinanceThe Provider will receive an annual retainer payment. This is to support on-going staff training and the delivery of the Service. The retainer payment will be a minimum of ?500 with an additional pro-rata top-up payment based on practice list size. Each Provider contracted to provide this Service will receive the following fees upon satisfactory performance of the following services:?82 insertion and follow-up fee per Service User for either an IUD or IUS?22 removal fee for an IUD/IUS?60 insertion fee for an implantable device ?30 removal fee for an implantable device?4 per returned Chlamydia test Where a removal and reinsertion are carried out in the same appointment, both the removal fee and the insertion fee can be claimed.Where data is not submitted to the Commissioner by the due date each month, the Provider must notify the Commissioner of the reasons why this has occurred. Claims for payments are via Outcomes4Health (see Schedule 2 of the contract for further details). Claims can only be back dated for up to a 3 month period. The commissioner is at liberty not to reconcile payments to the provider beyond an 8 week period of the original submission date service.The Provider will be eligible for an incentive payment of ?500 if they achieve a 10% uptake of Chlamydia screening in their 15-24 year old population (this will be subject to annual review and may be amended). This service specification is valid for the length of the contract (5 years), although will be subject to annual review.Appendix 1: Drugs / contraceptive devices that are commissioned for GP prescribing as part of the NYCC sexual health commissioned service from GPThe following drugs have been formally commissioned for prescribing by GPs by NYCC. This forms the list of sexual health drugs prescribed on FP10 that NYCC agrees to pay for.Intrauterine Contraceptive SystemsDrug Indication commissioned for MirenaFirst choice long acting intrauterine contraceptive system for women requiring contraception for 5 yearsJaydessAn option for women for whom long acting intrauterine contraception is indicated: Jaydess would be first line if women are requiring contraceptive cover for up to 3 years; and second line (to Mirena) if 5 years or more contraceptive cover is required.Contraceptive ImplantsNexplanon (etonorgestrel)Intrauterine Contraceptive Device - CoilsAncora 375 Cu Copper T380 AFlexi-T 300 Flexi-T+380 GyneFix intrauterine contraceptive implantLoad 375 Mini TT380 Slimline Multiload CU 375 Multi-Safe 375 Neo-Safe T380 Nova-T 380 Novaplus T 380 Ag (Normal, Mini) Novaplus T 380 Cu (Normal, Mini) Optima TCu380A SteriloadT-Safe 380A QL TT380 Slimline UT380 Short UT380 Standard Please note that the type of device and the size (where more than one is listed above) must be specified by the prescriber. ................
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