An update to the Hillingdon Independent GP Group

1. An updateto the Hillingdon Independent GP Group Teenage Pregnancy, Strategy on sexual health/HIV and contraception by Dr Bela Reed Clinical Specialist in Reproductive Health for Harrow/Hillingdon 18 August 2004

2. “sexual health” National and local references • Expert Committee on Chlamydia 1998 • Health Improvement Programme (HIMP) 1998 • Teenage Pregnancy Report by the Social Exclusion Unit 1999 • Strategy for Sexual Health and HIV 2001

3. Teenagers • England’s teenage pregnancy rates highest in Europe • In 1999 174,000 abortions were performed in England and Wales

4. What the papers say .. Daily Mail, March 18 2002

5. Teenage PregnancyCouncil of Europe figures per 1000 females aged 15-19 UNITED KINGDOM 32.9 Portugal 22.7 Greece 19.9 Ireland 16.1 Germany 12.4 Spain 12.1 France 11.8 Belgium 9.3 Italy 8.9 Denmark 8.8 THE NETHERLANDS 4.8

6. UK has highest rates of teenage births in Europe -worst in poorer areas and the vulnerable eg in care, excluded from school 1/3 of under 16s have sex before age 16 half do not use contraception first time most wished they had waited - sex forced or unwanted Half <16s and a third of <17s have abortion Higher infection risks 90% single mums - 50% chance relationship breakdown Poverty and unemployment through lack of education Higher illness and death rates (60% higher) Teenage PregnancyReport by the Social Exclusion UnitJune 1999

7. Teenage sex The law • “age of consent”is 16 years • Under 13 – intercourse is always unlawful whatever the circumstances Recent clarification in ‘Sexual Offences Act 2003’

8. The “Fraserruling” Gillick vs Wisbech and W Norfolk AHA 1989 <16 may receive treatment providing: • understands advice • discussthe value of parental support and persuade (encourgea) inform parents • likely to have sexual intercourse without treatment • if not treated, her physical or mental health likely to suffer • Is in her “best interest” to treat without parental consent

9. Teenage Sex – National Guidance • Many teenagers risk pregnancy rather than seek contraceptive advice • Many teenagers mistakenly fear that their GP cannot respect their confidentiality • The duty of confidentiality owed to a person under 16 years is as great as the duty owed to any other person • Any competent young person, regardless of age, can independently seek medical advice and give valid consent to medical treatment Confidentiality & people under 16 Guidance issued jointly by the BMA, GMSC, HEA, Brook Advisory Centres, FPA and RCGP

10. Local Guidelines on treatment of Young People • Over 16 can consent • under 16 if considered “competent” • Children’s Act there to protect children • Child’s wishes can over-rule parents wishes, but need medical support • make clear notes,check entries with child Jane Chapman Clinical Risk Manager, NW London Hospitals NHS Trust Jan 2002

11. Teenage Pregnancy Why? No single explanation - a complex issue but 3 main factors: • low expectations • ignorance • mixed messages

12. Teenage sex Some questions on present legal position …. • Is it enough to consider if a girl is “competent” and “sensible”? • Do we need some sort of objective assessment of psychological maturity? “A substantial proportion of women who started sex under age 16 consider in retrospect that this was too young” Welling K “Sexual behaviour in Britain. London: Penguin 1994

14. Strategy on Teenage Pregnancy The aims of the strategy • halving the rate of conception among the under 18s by 2010 • get more teenagers into education, training and employment to reduce long term social isolation

15. Teenage Pregnancy The Action Plan • a national campaign • ‘joined up’ action • better prevention • better support for pregnant teenagers and teenage parents

16. Teenage - Contraception Suitable methods are • Emergency contraception • combined oral contraceptive pills • injections • implants • “Double Dutch” “Many doctors have reservations about providing advice and contraception for girls aged under 16” - Brook

17. Report from the PHLS • 1 in 5 girls age12-15 who were diagnosed with STI were back within 12 months • Incidence of chlamydia in women <19 more than doubled between 1995 – 2000 (nearly 14,000 cases) • London accounts for 25% of all cases of chlamydia (64,000) 43% of gonorrhoea 40% of all syphylis cases (333 cases) From the Evening Standard 28 February 2002

18. Teenage - Contraception Denial of sexuality eg “we were on holiday” “I was at a party” “I was drunk” “He was so good looking” First sexual encounter “not wanting to look as if I wanted it” “not wanting to seem prepared”

19. Teenagers and contraceptive services Teenagers prefer to use FP clinics to their GPs Girls age19 or under attending FP clinics 14.2 per 100 Harrow 18% in 02/03 increased to 24% in 03/04

20. Contraceptive services for young people TPU advice on “best practice” • Improving access • age specific focus • confidentiality • non-judgmental staff • friendly atmosphere • publicity • involving young people

21. What about the boys? Need to understand • The “power imbalance” - pressure on girls to have unprotected sex • They may have their own anxieties eg performance, sexuality or acceptability Services should • Include them in the consultation • Discuss choice of method, teaching (act as a prompter) • know when or why condom or abstinence required • Know about emergency contraception In Harrow FP, 13% of first visits were male – 28% were < age 19 years. Majority (87%) registered for condoms

22. What about “safer sex”? • Previous campaigns have been counter-productive • Ignorance on consequences of promiscuity and believe that doctors can protect them • Misinformation eg condoms protect - Condom failure 15% eg What is safer sex? Majority believe it was ‘safe’ before but now is ‘safer’

23. The background to • strategy • The problems of STI • The problems of current • service provision • The cost of STI • The strategy • Better prevention • Better services • Special services • GUM • Abortion • Psychological • FGM • Education/training • Chlamydia

24. The background

25. HIV Latest UK figures on AIDS and HIVfrom AIDS & HEPATITIS Digest N0.89, May 2002 • 1999: 19 179 HIV+ • 2000; estimated 30 000 HIV+ • By Dec 2001,48 226 HIV+ with AIDS 6 047 (13%) death with/without AIDS 14 550 (30%) HIV virus

26. The problems 1. Inequality • The rates of GC highest in inner city areas higher among black and ethnic minorities >10 times compared to whites • HIV infection high especially among Africans • Link with social deprivation – girls from deprived backgrounds are 10 times more likely to become teenage mothers

27. The problems 2. Inequity of current service provision • Significant variations in the way services are provided including health promotion and HIV prevention eg abortions funded by NHS vary between 46% and 96% • Delays in urgent GUM appointments up to one week and routine appointments take up to 4 weeks

28. THE CO$T$ • The prevention of unplanned pregnancies can save the NHS £2.25 billion a year • The lifetime treatment costs for one HIV+ individual is estimated between £135,000 to £181,000 • Dramatic reduction in costs associated with preventable infertility • Teenage parents more likely to live in poverty

29. The Strategy 1. Better prevention Targeted sexual health information for specific groups eg • Young people especially those in/leaving care • Black and minority ethnic groups • Gay and bisexual men • Injecting drug misusers • People living with or affected by HIV • Sex workers • People in prison or youth offending establishments • FGM

30. 2. Better services The main elements • Contraceptive care • abortions • Diagnosis and treatment of STI and HIV • Prevention of STI and HIV • Services for psychological and sexual problems

31. Better services i. A new model of working NHS servicesare “fragmented care and inconsistent advice – availability, quality and choice vary” Primary Care A&E FP GUM OBS & GYNAE YP Services NHS walk-in centres

32. Better Services :A new model of working ii. Managed service networks • Providers collaborating to plan services jointly so that they deliver a comprehensivelocal service • three levelsof services that meets the needs of the local population • Broader role for primary care 1 3 2

33. Sexual history and risk assessment Contraceptive information and services Cervical cytology screening and referral Pregnancy testing and referral Wider provision of EC eg Pharmacy, A&E, MATS STI testingfor women HIV testingand counselling Assessment and referral of men with STI symptoms Hepatitis B immunisation Better Services: A new model of workingLevel one – mainly in primary care also other open access services

34. IUD insertion Contraceptive implant vasectomy Testing and treating sexually transmitted infections Partner notification Invasive STI tests for men Level two -Primary care teams with special interest now ‘advanced’ and ‘enhanced’ services - FP clinics - GUM clinics

35. Level three – “clinician teams” for more complex or intensive needs. Could be across more than one PCT • Outreach for STI prevention • Specialised infections management including partner notification • Specialised HIV treatment and care (?Strategic HAs) • Outreach contraception services • Highly specialised contraception eg complex medical termination of pregnancy psychosexual counselling sexual assault female sterilisation • Wider remit for clinical governance, guidelines etc

36. Better Services- Access and information All services should • review their location and opening hours to match their local population needs • Involve users and potential users in developing access policies

37. To be evaluated • One-stop sexual health clinics • Primary care youth services • Young offenders institutions

38. 3. Special services – areas for development:Genito-Urinary Medicine services • Increasing access • Shorter waiting times • Improve comprehensiveness and effectiveness of service • Increase in number and role of health advisers

39. Abortion services NHS funded in line with RCOG guidelines Appointments within 3 weeks of first consultation Referral for earlier TOP Availability of medical termination Information on local counselling services readily available Telephone helplines

40. Psychological and sexual problems • Need to discuss sexual problems in general practice and sexual health services • Referral to specialist services • DH development of training and standards.

41. Female genital mutilation • Eradication • Child protection measures • Special care and treatment for those already damaged

42. Professional education and training • Everyoneworking in the field • Training needs to cover core skills and issues • Professional (medical) training undergraduate curricula STI Foundation course DFFP LoCs for IUT and SDI • Role of nurses – referral, prescribing, specialists and consultants • Role of Health Advisers – strengthened and better defined

43. Chlamydia • Affects 10% of sexually active women <25 • Causes 1/3 of all cases of infertility • Usually asymptomatic • Reported cases in Britain: 1995 30,877 2000 64,000

44. Chlamydia screening screening for chlamydia • All attending GUM clinics • FP clinics/GPs –random testing for 16-24 year olds • At termination of pregnancy • Pre-IUD insertions and other intrauterine interventions Risk reduction programmes • Giving good information • Dealing promptly with positive cases – treatment and partner notification

45. Intra-uterine ContraceptionChlamydia Screening RISK MARKERS for Chlamydia • Age <25 years • New sexual partner in the last 3 months • 2 or more partners in the last 12 months • History of Chlamydia/BV/PID or NSU in partner • Symptoms and/or signs of cervicitis/PID

46. Local Guidelines for IUDScreening for Chlamydia