Key Clinical Indicators for Sexual Health: Population Based KCIs Data for 2006 Introduction...2 Chlamydia...3 Access to Male & Female Sterilisation...8 Female Sterilisation...8 Male Sterilisation / Vasectomy...11 Termination of Pregnancy...18 HIV Therapy...23 Hepatitis B Vaccination for MSM...23 Long Acting Reversible Methods of Contraception (LARC)...23 1
Introduction Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health highlighted the need to monitor sexual health service development both nationally and at an NHS board level. A set of key clinical indicators (KCIs) has been developed for this purpose. This document reports on the chlamydia, sterilisation and termination of pregnancy indicators with data from calendar year 2006. The data on HIV Therapy has been delayed and will be published at a later date. Due to changes in data collection methodology, data for hepatitis B vaccination for men who have sex with men (MSM) will be reported upon in Autumn 2008. The key clinical indicators for sexual health have been developed by the Action 12 subgroup on behalf of the National Sexual Health Advisory Committee (NSHAC). The KCIs are part of the wider quality framework for sexual health. The indicators help to inform the development of the Quality Improvement Scotland (NHS QIS) Sexual Health Service Clinical Standards and also the National Sexual Health System (NaSH) with its associated datasets, developed by the National Clinical Dataset Development Programme (NCDDP). The indicators reported upon in this report are as follows: Chlamydia The proportion of the population within each NHS board having a chlamydia test and the proportion of those tests which are positive. Access to Male & Female Sterilisation The number of female sterilisation procedures and male vasectomies performed by each NHS board per women and men of reproductive age and the waiting times for these procedures. Termination of Pregnancy Percentage of termination of pregnancy procedures taking place at less than or equal to nine weeks gestation per NHS board. The three indicators above in addition to the indicators on HIV therapy, hepatitis B vaccination for men who have sex with men (MSM) and on long acting reversible methods of contraception (LARC) represent the Population Based Indicators. For more information on the KCIs go to www.isdscotland.org/kci Purpose of the report This report presents the second set of data on these indicators and thus provides a comparison on the baseline as well as between NHS boards. The baseline report looking at 2005 data can be accessed at www.isdscotland.org/kci The third set of data will be published in autumn 2008. 2
Chlamydia The proportion of the population within each NHS board having a chlamydia test and the proportion of these tests which are positive. Evidence Base / Reasons for selection Chlamydia trachomatis is the most prevalent bacterial cause of sexually transmitted infection (STI) in the United Kingdom. Consequences of chlamydia infection may include pelvic inflammatory disease, which can progress to ectopic pregnancy and infertility. However, as an estimated 70% of infected women are asymptomatic, identification remains a challenge (Scottish Intercollegiate Guidelines Network. (Management of Genital Chlamydia trachomatis Infection. A national clinical guideline. No.42. Edinburgh: SIGN, March 2000.) In Scotland, laboratories return counts of the number of positive chlamydia tests to Health Protection Scotland (HPS) on a weekly, monthly or quarterly basis. Information is not routinely collected centrally from laboratories about the number of samples testing negative for chlamydia. Accordingly, it has not been possible in the past to describe chlamydia testing activity across Scotland, nor to define differences in testing or prevalence of infection in those undergoing testing by age, sex and NHS board region. Data Collection A proforma was sent to each of the NHS laboratories that perform chlamydia testing in Scotland. Using this proforma, aggregate data (by 5 year age band and gender) about chlamydia tests performed during 2006 were collected. Baseline Data, 2006 Commentary In 2006, 226,528 chlamydia tests were performed in persons aged 10 years and over. This compares with 222,709 tests performed in 2005 and represents a 1.7% increase. The data are aggregated and presented in two key age groups, 15 24 years and 25 49 years, for both men and women. It should be noted that the total contains some equivocal, unconfirmed or indeterminate results (overall 1.8% of tests) as well as some duplicate tests for the same individual. It is estimated that approximately 5 20% of tests in a calendar year are repeat ones on the same individual as a result of; (i) repeat samples taken at a single consultation, (ii) samples taken at different consultations for the same clinical episode and, (iii) samples taken for clinical episodes occurring more than once. In addition, an estimated 0.5% of tests were performed on non genital (ophthalmic) samples. An increase in total tests was observed for both men (5%) and women (0.6%) aged 15 49. While an increase in total tests was observed for men in both the 15 24 (3.4%) and 25 49 (6.5%) age groups and women aged 25 49 (1.6%), a small decrease was observed in the total tests in women aged 15 24 (0.4%). The majority (77%) of testing was performed on women; this is a similar proportion to that reported in 2005. Although the majority of samples testing positive (70%) were from persons aged less than 25, less than half of all 3
testing (45%) was performed on persons belonging to this age group. This compares with 73% and 46%, respectively in 2005. Table 1 Number of chlamydia tests performed and percentage of positive tests by gender, age group*, and NHS board region of testing, 2006. Total number of tests performed (% samples testing positive) Sex Men Women NHS board region of testing Age 15 to 24 years 25 to 49 years 15 to 24 years 25 to 49 years Ayrshire and Arran (AA) 1284 (20) 1271 (10) 4570 (14) 5432 (4) Borders (BR) 293 (16) 345 (11) 1222 (10) 1231 (4) Dumfries and Galloway (DG) 633 (24) 457 (12) 2673 (12) 2856 (2) Fife (FF) 1336 (21) 1366 (10) 5160 (11) 6389 (7) Forth Valley (FV) 1220 (20) 945 (12) 4372 (12) 4128 (3) Grampian (GR) 2639 (18) 3100 (11) 9617 (11) 10529 (3) Greater Glasgow & Clyde # (GGC) 5696 (17) 7317 (9) 21,167 (12) 23,199 (3) Highland (HG) 947 (18) 1067 (8) 3484 (11) 4550 (2) Lanarkshire (LN) 1363 (23) 2210 (14) 4766 (17) 8790 (4) Lothian (LO) 4615 (16) 7392 (8) 15115 (10) 16482 (3) Tayside (TY) 2177 (18) 1931 (11) 6488 (14) 6702 (3) Scotland 22,203 (18) 27,401(10) 78,634 (12) 90,288 (4) * Data on those aged less than 15 and over 50 have been omitted. # The laboratories in the former Argyll & Clyde NHS Board are located within the new Greater Glasgow & Clyde NHS Board. Note: Island NHS boards are not included as the samples are sent to laboratories on the mainland for testing. Of those tested, 18% (4062) of young men aged less than 25 were positive for chlamydia compared to 12% (9516) of young women. This is a similar proportion to that reported in 2005. In those aged greater than 25 who were tested for chlamydia, 10% (2668) of men versus 4% (3131) of women were positive. In 2005, the corresponding proportions were 9% and 3% Three times as many positive diagnoses were made in women undergoing testing who were aged less than 25 than in older women. In men, 60% of positive diagnoses were in those aged less than 25 years. The highest proportion of samples testing positive was identified among women aged 15 19 (14%) and men aged 15 24 (18%); the proportion of positive tests declined in older age groups. However, the proportion of positive tests was higher in men, compared to women, among all age groups. This 4
may reflect the fact that men are more likely to be tested when they present with symptoms. Across all NHS board areas, there was little variation in the percentage of positive chlamydia tests among women; o in those aged 15 24, this ranged from 10% to 14% (median 12%) and, o in those aged 25 49, from 2% to 4% (median 3%). The exceptions were in Lanarkshire NHS Board where the percentage of positive tests was 17% among those aged 15 24 and, in Fife NHS Board where 7% of tests were positive among those aged 25 49 (Figure 1a). Across all NHS board areas, the percentage of positive tests among men ranged from; o 16% to 24% (median 19%) among those aged 15 24 and, o 8% to 14% (median 10.5%) among those aged 25 49. The highest percentage of positive tests among men aged 15 24 were observed in Dumfries & Galloway (24%) and Lanarkshire (23%) NHS Boards. In addition, the highest proportion positive among men aged 25 49 was noted in Lanarkshire NHS Board. In 2006, there was little regional variation in chlamydia testing rates among women. Although an estimated 5 20% of chlamydia tests undertaken on individuals in a calendar year are repeats, the data indicate that between 20% and 30% of women, aged 15 24, in each NHS board region had a test performed. (Figure 1a) This is similar to the rates reported in 2005. There were two exceptions: the highest rate of testing among women in this age group was observed in Dumfries and Galloway NHS Board (37%) and the lowest rate was observed in Lanarkshire NHS Board (14%). The same exceptions were also noted in these NHS boards in 2005. Testing is encouraged among young people in Dumfries & Galloway NHS Board as a result of increased awareness of the need for testing among primary care staff; this is enhanced by the availability of youth clinics in every town with a secondary school these operate during lunch times and after school where possible. In addition, in partnership with schools, parents and primary care, chlamydia testing is now available in some schools. In Lanarkshire NHS board, the lower testing rates, in 2006, may be linked to lower rates of opportunistic screening in young people as recommended by the SIGN guidelines and this issue is being addressed. Among men aged 15 24, between 4% and 8% of the population in each NHS board region had a test performed (Figure 1b). The highest rates were observed in Tayside (8.4%), Lothian (8.2%), Dumfries and Galloway (7.9%) and Grampian (7.7%) NHS Boards. The lowest rate among men in this age group was observed in Lanarkshire (3.7%) NHS Board. These observations are similar to those reported in 2005. 5
Data were available from ten of the fifteen laboratories regarding the source of specimens for chlamydia testing. Whilst there was some regional variation, the majority of testing in men (69%) is performed by the genitourinary medicine (GUM) clinics and 24% by primary care. In women, 48% tests are received from the primary care setting, 18% and 14% are received from the hospital and family planning setting respectively and 17% from the GUM clinic setting. Figure 1a Rates of chlamydia tests performed per 1000 women and percentage of positive tests by age group and NHS board region of testing, 2006. 15 to 24 years 25 to 49 years % pos 15 24 % pos 25 49 400 18 Testing rate per 1000 population 350 300 250 200 150 100 50 0 16 14 12 10 8 6 4 2 0 Proportion positive Ayrshire & Arran Borders Dumfries & Galloway Fife Forth Valley Grampian Greater Glasgow & Clyde Highland Lanarkshire NHS board of testing Lothian Tayside 6
Figure 1b Rates of chlamydia tests performed per 1000 men and percentage of positive tests by age group and NHS board region of testing, 2006. 15 to 24 years 25 to 49 years % pos 15 24 % pos 25 49 Testing rate per 1000 population 90 80 70 60 50 40 30 20 10 0 30 25 20 15 10 5 0 Proportion positive Ayrshire & Arran Borders Dumfries & Galloway Fife Forth Valley Grampian Greater Glasgow & Clyde Highland Lanarkshire NHS board of testing Lothian Tayside Conclusion In Scotland, there has been no significant increase in the level of chlamydia testing between 2005 and 2006. In a similar observation to that in 2005, the majority of testing (77%) was performed on women. This likely reflects the SIGN guideline recommendations for opportunistic screening in women in addition to testing in certain clinical situations, for example termination of pregnancy. For men, there is a focus on screening those with symptoms, but no recommendations for opportunistic testing outside the GUM clinic setting. Although sexually active individuals aged less than 25 are at greatest risk of chlamydia infection and the majority (70%) of positive tests were noted in this age group, less than half (45%) of all chlamydia testing in Scotland during 2006 (and 2005) was performed on those aged less than 25. For women, 47% of all tests and 75% of positive diagnoses were in those aged 15 24. For men, 45% of all tests and 60% of all positive diagnoses were in those aged 15 24. These observations indicate that chlamydia testing in sexually active people aged less than 25 should be actively encouraged: improvements in screening opportunities, especially for men, and increased targeting of young people, those most at risk of infection, are required across Scotland to help address the burden of chlamydia infection. 7
Access to Male & Female Sterilisation The number of female sterilisation procedures and male vasectomies performed by each NHS Board per women and men of reproductive age and the waiting times for these procedures. Evidence Base / Reasons for Selection of Indicator The ONS Omnibus Survey on Contraception and Sexual Health reports that in the UK in 2006/07: 9% of women under 50 were sterilised. 17% of men under 70 had undergone a vasectomy. Sterilisation, particularly male sterilisation, is highly cost effective, and failure rates are extremely low (Male and Female Sterilisation Guideline, Royal College of Obstetricians and Gynaecologists, January 2004). The data are presented by NHS board of residence and NHS board of treatment. The rates for NHS board of treatment are calculated using board of residence population data so may not account for those patients who have cross border treatment. Female Sterilisation Data Collection Female sterilisation data are routinely collected by Information Services Division (ISD) and these data are obtained from Scottish Morbidity Records (SMR) for acute hospital discharge (SMR01) and for maternity episodes (SMR02). Waiting times data can only be obtained from SMR01, where almost all female sterilisations are recorded. Very few sterilisations are recorded on SMR02 (387 procedures in 2006) and waiting times are not applicable for SMR02 as the sterilisation procedure takes place during the maternity episode. SMR02 Data It is not possible to publish the SMR02 data on female sterilisations in this report due to problems around data completeness. The sterilisations carried out outside the maternity episode and recorded on SMR01 present more useful data in terms of service provision, waiting times and performance monitoring as they take place outside the maternity episode and require service planning in order that the procedure takes place within a reasonable timeframe. 8
Baseline Data, 2006 SMR01 Acute Discharge Summary Table 2a Rates of Female Sterilisation Episodes per 10, 000 women (aged 15 44) and waiting times*, by NHS Board of Residence, 2006 NHS board Rates Rates 95% Interval % Waiting >3 months Waiting 95% Interval % Waiting >6 months Waiting 95% Interval Ayrshire and Arran 26.9 23.4 to 31.0 51 43.99 to 58.07 7 3.95 to 11.45 Borders 18.0 13.0 to 25.1 0 0 to 8.6 0 0 to 8.6 Dumfries and Galloway 25.5 20.0 to 32.5 34 23.50 to 46 2 <0.01 to 9 Fife 26.0 22.6 to 30.0 40 33.16 to 47.03 7 4.4 to 12.2 Forth Valley 27.9 24.0 to 32.5 33 26.58 to 40.84 5 2.33 to 9.42 Grampian 11.7 9.8 to 13.9 41 33.14 to 50.3 6 2.58 to 11.48 Greater Glasgow and Clyde 16.6 15.1 to 18.3 33 28.34 to 37.11 3 1.53 to 4.80 Highland 16.8 13.7 to 20.7 38 28.44 to 48.11 3 0.73 to 9.75 Lanarkshire 18.7 16.4 to 21.4 56 49.11 to 62.21 15 11 to 20.62 Lothian 12.9 11.4 to 14.7 60 53.99 to 66.36 10 6.50 to 14.19 Orkney Islands 25.7 13.7 to 48.8 11 <0.01 to 45.67 0 0 to 33.3 Shetland Islands 17.2 8.5 to 35.3 57 24.98 to 84.25 0 0 Tayside 22.8 19.7 to 26.5 25 18.99 to 31.82 6 3.05 to 10.44 Western Isles 18.1 9.3 to 33.9 25 6.31 to 59.91 13 0.11 to 49.22 NHSScotland 18.5 17.7 to 19.3 41 38.39 to 42.75 6 5.41 to 7.60 * Waiting times calculations include patients with ASCs Availability Status Codes certain specified circumstances when it may not be possible to meet a waiting time standard. The recording of ASCs on inpatient/day case discharge data is not mandatory and consistency of recording will vary across NHSScotland. Table 2b Rates of Female Sterilisation Episodes per 10, 000 women (aged 15 44) and waiting times* by NHS Board of Treatment, 2006 NHS board Rates Rates 95 % Intervals % Waiting >3 months Waiting 95% Intervals % Waiting >6 months Waiting 95% Intervals Ayrshire and Arran 26.6 23.1 to 30.7 52 44.49 to 58.64 7 3.99 to 11.57 Borders 21.6 16.0 to 29.2 0 0 0 0 Dumfries and Galloway 25.9 20.4 to 32.9 35 24.45 to 46.92 2 <0.01 to 8.88 Fife 25.2 21.8 to 29.1 41 33.79 to 47.92 8 4.54 to 12.59 Forth Valley 27.8 23.8 to 32.4 33 26.19 to 40.45 5 2.34 to 9.48 Grampian 11.7 9.9 to 14.0 42 33.62 to 50.74 6 2.56 to 11.39 Greater Glasgow & Clyde 19.2 17.6 to 20.9 32 28.52 to 36.69 3 1.78 to 4.91 Highland 9.9 7.6 to 12.9 51 37.88 to 63.88 4 0.31 to 13.49 Lanarkshire 16.1 14.0 to 18.6 57 50.05 to 64.10 17 11.89 to 22.61 Lothian 13.1 11.5 to 14.9 60 53.27 to 65.60 10 6.42 to 14.02 Orkney Islands 25.7 13.7 to 48.8 11 <0.01 to 45.67 0 0 Shetland Islands 14.7 6.9 to 32.0 50 18.76 to 81.24 0 0 Tayside 23.5 20.3 to 27.2 25 18.94 to 31.57 6 2.96 to 10.15 Western Isles 15.9 7.8 to 32.7 29 7.56 to 64.76 14 0.53 to 53.35 NHSScotland 18.5 17.7 to 19.3 41 38.39 to 42.75 6 5.41 to 7.60 * Waiting times calculations include patients with ASCs Availability Status Codes certain specified circumstances when it may not be possible to meet a waiting time standard. The recording of ASCs on inpatient/day case discharge data is not mandatory and consistency of recording will vary across NHSScotland. 9
Commentary In this context, the waiting time is calculated as the difference between the date the decision was made to operate (waiting list date) to the actual date of procedure. 18 women per 10,000 (aged 15 44) had a sterilisation procedure in 2006, compared to 20 in 2005. Six NHS boards of treatment recorded rates lower than this, however it is not possible to determine whether this is due to lack of availability of the procedure or good availability of other long term contraceptive options such as LARC (long acting reversible contraception). Five of these six boards, however, have a higher percentage of women waiting over three months than the national total (41%). Two boards, NHS Lothian and NHS Lanarkshire, also show a higher percentage of waiting at over six months. This may suggest a limited availability of the female sterilisation service. The two boards with the lowest rates of female sterilisation, Grampian and Highland, showed high rates of LARC uptake in the 2007 LARC report [www.isdscotland.org/kci]. Waiting times figures for 2006 data show considerable variation between NHS boards. Data in tables 2a and 2b show that 41% waited over three months for a sterilisation procedure. Eight boards have reduced their waiting times since 2005. In NHS Borders no patients waited more than three months, compared with 60% waiting over three months in NHS Lothian. 17% of patients treated in NHS Lanarkshire waited over six months for the procedure. 10
Male Sterilisation / Vasectomy Data Collection Some vasectomy data can be reliably obtained from SMR01. However, the procedure is also performed in settings other than the acute, including community family planning clinics and GP surgeries, where SMR01 data are not routinely collected. In order to obtain this information, the lead clinicians for sexual health were asked to collate these data for their NHS board and return it to ISD. Baseline Data, 2006 Information on vasectomy procedures in 2006 has been obtained in two ways: through SMR01 and directly from the NHS Boards. It should be noted that at this time, it is not possible to quality assure the data provided directly by the NHS boards to the same extent as the national data returns (SMR01). 11
Table 2c NHS Board Data Total Vasectomy Numbers in 2006 NHS Board Number performed inhospital Number recorded elsewhere (SMR01 HBT) Where recorded Total Ayrshire and Arran 509 0 SMR01 509 Borders 154 0 SMR01 154 Dumfries and Galloway 181 0 SMR01 181 Fife 479 1 SMR01 (479) SMR00 (1) 480 Forth Valley* 72 Data not available Data not available 72 Golden Jubilee National Hospital 14 N/A SMR01 14 Grampian 216 747 Local system (341) SMR00 (406) 963 Greater Glasgow and Clyde 442 1474 SMR01 (216) Local System SMR01 1916 Highland 362 0 SMR01 362 Lanarkshire 20 320 Local System SMR01 340 Lothian 361 621 Local System SMR01 982 Orkney 28 0 SMR01 28 Shetland 25 0 SMR01 25 Tayside 466 98 SMR01 SMR00 564 Western Isles 21 0 SMR01 21 Total 3350 6611 * NHS Forth Valley is not able to present data outwith SMR01 for 2006 due to changes in local reporting procedures. ** NHS Tayside is not able to present full SMR00 data due to activity recording issues 12
In 2006 SMR01 recorded a total of 3,350 vasectomies in Scotland performed inhospital. The data supplied by the NHS boards, which cover acute, outpatient and community procedures includes those procedures recorded under SMR01, and shows that from the data available, 6,611 vasectomies were carried out in total in 2006. Table 2d Total rates of vasectomy per 10, 000 men (aged 15 59) and waiting times* by NHS Board of Treatment, 2006 NHS board Rates Rates 95% Interval % Waiting >3 months Waiting 95% Interval %Waiting >6 months Waiting 95% Interval Ayrshire and Arran 48.4 44.4 to 52.8 68.9 64.8 to 72.8 10 8.0 to 13.4 Borders 49.5 42.3 to 58.0 47 39.1 to 54.6 10 5.9 to 15.6 Dumfries and Galloway 44.1 38.1 to 51.0 57 49.6 to 63.9 10 6.3 to 15.3 Fife 44.9 41.0 to 49.0 62 58.0 to 66.7 13 10.4 to 16.5 Forth Valley* Grampian 57.7 54.2 to 61.5 31 Data not available 27.8 to 34.0 7 5.1 to 8.5 Greater Glasgow & Clyde 52.1 49.8 to 54.5 14 12.4 to 15.5 4 2.9 to 4.5 Highland 39.9 36.1 to 44.3 48 43.2 to 53.5 16 12.8 to 20.5 Lanarkshire 20.3 18.2 to 22.5 34 29.4 to 39.7 9 6.6 to 13.1 Lothian** 39.0 36.7 to 41.5 Data not available Orkney Islands 48.0 33.3 to 69.3 4 0 to 19.2 0 0 to 10.7 Shetland Islands 37.1 25.2 to 54.7 4 0 to 21.1 4 0 to 21.9 Tayside *** 41.1 37.6 to 45.0 42 38.1 to 47.0 7 5.0 to 9.8 Western Isles 27.3 17.9 to 41.7 29 13.6 to 50.2 10 1.5 to 30.1 The data presented in the table above represent a combination of SMR01 data and that presented by the NHS Boards directly. It should be noted that while SMR counts waiting time from the date the decision was made to operate, to the actual date of operation, the Boards were asked for the wait from GP/Self referral to procedure. SMR01 Waiting times calculations include patients with ASCs Availability Status Codes certain specified circumstances when it may not be possible to meet a waiting time standard. The recording of ASCs on inpatient/day case discharge data is not mandatory and consistency of recording will vary across NHSScotland. * NHS Forth Valley is not able to present data outwith SMR01 for 2006 due to changes in local reporting procedures. **NHS Lothian is not able to specify local waiting times data for 2006 so total waiting times data are not available ***Waiting times for NHS Tayside are for SMR01 procedures only Table 2d presents the information supplied directly from the NHS boards. Where SMR01 data are present, the numbers and waiting times from the ISD NHS board of treatment data are used for consistency. 13
SMR01 (Acute Discharge Summary) Table 2e Vasectomy rates per 10, 000 men (aged 15 59) and waiting times* by NHS Board of Residence, 2006 NHS board Rates Rates 95% Interval % Waiting >3 months Waiting 95% Interval % Waiting >6 months Waiting 95% Interval Ayrshire and Arran 49.6 45.6 to 54.0 68.2 64.1 to 72.1 10.5 8.2 to 13.5 Borders 49.8 42.6 to 58.3 47.7 40.0 to 55.6 11.0 6.9 to 17.0 Dumfries and Galloway 43.6 37.7 to 50.5 57.0 49.7 to 64.0 9.5 5.9 to 14.8 Fife 53.5 49.4 to 58.1 63.8 59.8 to 67.7 13.8 11.2 to 16.9 Forth Valley 7.9 6.2 to 10.0 29.9 20.2 to 41.7 20.9 12.8 to 32.2 Grampian 12.9 11.3 to 14.7 51.2 44.5 to 57.8 18.6 13.9 to 24.4 Greater Glasgow & Clyde 9.8 8.9 to 10.9 26.0 21.8 to 30.8 8.0 5.6 to 11.3 Highland 48.0 43.7 to 52.7 47.1 42.5 to 51.8 15.6 12.5 to 19.4 Lanarkshire 2.2 1.6 to 3.0 59.5 43.5 to 73.7 32.4 19.6 to 48.6 Lothian 12.3 11.0 to 13.8 88.7 84.7 to 91.8 72.6 67.4 to 77.3 Orkney Islands 48.0 33.3 to 69.3 3.6 0 to 19.2 0.0 0 to 10.7 Shetland Islands 37.1 25.2 to 54.7 4.0 0 to 21.1 4.0 0 to 21.1 Tayside 36.6 33.3 to 40.3 42.9 38.2 to 47.7 7.0 4.9 to 9.9 Western Isles 29.9 20.0 to 44.8 34.8 18.7 to 55.2 17.4 6.4 to 37.7 NHSScotland 21.6 20.9 to 22.4 54.1 52.5 to 55.8 17.6 16.4 to 19.0 * Waiting times calculations include patients with ASCs Availability Status Codes certain specified circumstances when it may not be possible to meet a waiting time standard. The recording of ASCs on inpatient/day case discharge data is not mandatory and consistency of recording will vary across NHSScotland. Table 2f Vasectomy rates per 10, 000 men (aged 15 59) and waiting times* by NHS Board of Treatment, 2006 NHS board Rates Rates 95% Intervals % Waiting >3 months Waiting 95% Intervals % Waiting >6 months Waiting 95% Intervals Ayrshire and Arran 48.4 44.4 to 52.8 69.0 64.8 to 72.8 10.4 8.0 to 13.4 Borders 49.5 42.3 to 58.0 46.8 39.1 to 54.6 9.7 5.9 to 15.6 Dumfries and Galloway 44.1 38.1 to 51.0 56.9 49.6 to 63.9 9.9 6.3 to 15.3 Fife 44.8 41.0 to 49.0 62.4 58 to 66.7 13.2 10.4 to 16.5 Forth Valley 8.5 6.7 to 10.7 43.1 32.3 to 54.6 23.6 15.2 to 34.7 Grampian 13.0 11.3 to 14.8 51.9 45.2 to 58.4 19.0 14.2 to 24.8 Greater Glasgow & Clyde 12.0 11.0 to 13.2 27.1 23.2 to 31.5 8.6 6.3 to 11.6 Highland 39.9 36.1 to 44.3 48.3 43.2 to 53.5 16.3 12.8 to 20.5 Lanarkshire 1.2 0.8 to 1.8 55.0 34.2 to 74.2 25.0 10.8 to 47.3 Lothian 14.3 12.9 to 15.9 88.9 85.2 to 91.8 66.8 61.7 to 71.4 Orkney Islands 48.0 33.3 to 69.3 3.6 0 to 19.2 0.0 0 to 10.7 Shetland Islands 37.1 25.2 to 54.7 4.0 0 to 21.1 4.0 0 to 21.9 Tayside 41.1 37.6 to 45.0 42.5 38.1 to 47.0 7.1 5.0 to 9.8 Western Isles 27.3 17.9 to 41.7 28.6 13.6 to 50.2 9.5 1.5 to 30.1 Scotland 21.6 20.9 to 22.4 54.1 52.5 to 55.8 17.6 16.4 to 19.0 * Waiting times calculations include patients with ASCs Availability Status Codes certain specified circumstances when it may not be possible to meet a waiting time standard. The recording of ASCs on inpatient/day case discharge data is not mandatory and consistency of recording will vary across NHSScotland. 14
Commentary Data were requested from the NHS boards as SMR01 only records those patients who have the procedure in hospital. Two major pathways can be identified 1. GP/Community Family Planning Clinic Outpatient Consultation Hospital Procedure GP/Community Family Planning Clinic Hospital Procedure 2. Self referral/gp/hospital Family Planning Clinic In 2005 it was anticipated that a great deal more procedures were taking place outwith the hospital sector in general practice, family planning, and in outpatients. However, the information from the NHS Boards did not support this and the data provided for 2006 confirms that this is still the case. GPs GPs perform vasectomies in two NHS boards, NHS Grampian and NHS Lanarkshire. Community and Family Planning clinics Refer patients to hospital for vasectomy Offer a vasectomy service within the clinic NHS Lothian The Dean Terrace Family Planning clinic and the Leith Community Treatment Centre carried out 621 vasectomies in 2006. NHS Greater Glasgow and Clyde The Sandyford Initiative Family Planning clinic provides the vasectomy service for the whole of NHS Greater Glasgow and Clyde, apart from those who require general anaesthetic. This includes patients resident in other NHS Boards. In 2006, the Sandyford clinic carried out 1474 vasectomies. 15
Long term data male and female sterilisation since 2000 Figure 2a Numbers of female and male sterilisations 2000 2006 by NHS Board of Treatment 7000 6000 5000 4000 3000 2000 1000 0 2000 2001 2002 2003 2004 2005 2006 All Vasectomies SMR01 Males SMR01 Females Figure 2a shows the national trend in male and female sterilisation since 2000 using SMR01 data and data supplied directly from the boards. It should be noted that as SMR01 only covers NHS hospital procedures it does not include all vasectomies undertaken since 2000. Female sterilisations have reduced by more than 60%. Vasectomies performed in hospital have reduced by almost 40%. In 2006, 51% of all vasectomy procedures were not performed as inpatient or daycase procedures (an increase from 49% in 2005). A total of 43 per 10,000 men (aged 15 59) in Scotland had a vasectomy in 2006. 2006 data shows a slight increase in the numbers of vasectomies performed inhospital since 2005 (3,174 vs. 3,350) and a rise in the total numbers (6,457 vs. 6,611) Figure 2a clearly shows the downward trend in female sterilisation. The possible reasons for these changes are discussed in the commentary below, the most significant being the advances around long acting reversible methods of contraception (LARC) and its increasing popularity. The report published on the LARC indicator in 2007, shows that the uptake of very long acting reversible methods of contraception in Scotland is increasing. www.isdscotland.org/kci. 16
Waiting times As female sterilisation can only take place in the acute setting there is a risk of long waiting times and unlike male sterilisation there are no alternative community based facilities at which the procedure can take place. Long Acting Reversible Methods of Contraception (LARC) The increased availability of LARC offers an alternative to sterilisation and Provides a long term, reliable and reversible method of contraception, with little or no compliance required. Avoids an invasive and potentially risky procedure in hospital GP surgeries often offer the contraceptive injection (Depo Provera) but intrauterine devices (IUD), intrauterine systems (IUS / Mirena) and implants (Implanon) are offered less often and sometimes not at all. Family Planning clinics are usually able to offer women all four methods. Data published by the DASH project for the key clinical indicator on LARC reports that in 2006/07 only 34 per 1000 women (aged 15 49) were using very long acting methods of contraception (Implanon, Mirena and IUD). The rates however, are increasing. Conclusion The reduction in female sterilisation since 2000 implies that women may be looking for less intrusive ways of ensuring long term contraception such as long acting reversible methods of contraception. Although it cannot be proven that the decline in numbers of sterilisations and the notable increase seen in the uptake of LARC are directly related, the relationship between these statistics should not be dismissed. Vasectomy offers men a safe and reliable method of contraception and should be easy and quick to access. A number of boards offer the procedure via general and urology lists indicating that the availability of this procedure may be restricted. Those services outwith hospital are offering a more easily accessible service, for example in NHS Lothian and Greater Glasgow and Clyde, to which the patient can self refer or be referred via the GP. This also means the patient is not sharing a hospital waiting list with other patients who might be deemed to be of higher priority surgically. These services outwith hospital, however, are limited. The development of more community services, including GPs, offering vasectomies has the potential to significantly increase the availability and accessibility of vasectomy and reduce waiting times. 17
Termination of Pregnancy Percentage of termination of pregnancy procedures taking place at less than or equal to nine weeks gestation per NHS Board. Evidence Base / Reasons for Selection of Indicator The earlier a termination of pregnancy procedure is performed, the less physical complications and psychological distress experienced (The Care of Women Requesting Induced Abortion Guideline, Royal College of Obstetricians and Gynaecologists, September 2004). In addition, there are cost efficiencies to the NHS which have been demonstrated in England and Wales ( The Economics of Sexual Health Nigel Armstrong and Cam Donaldson fpa 2005). There is a wide variation in the gestation at which termination of pregnancy procedures are performed between NHS boards. There is evidence that organisational change can improve access and efficiency. This indicator will help to promote access, choice and efficiency standards across the system, including primary care, sexual & reproductive health clinics, voluntary services and hospital services as well as improving how they work together. All women need time to consider their position and seek counselling as necessary. For some women, the earliest possible procedure may not be beneficial, but for women in general, the earlier the procedure is performed, the less the physical complications and psychological distress. This indicator seeks to promote optimal quality of care for this group of women, by helping to remove bureaucratic delays or inefficiencies that increase suffering. It is recognised that a small minority of women may need longer to make a decision, present late or delay the decision; this is however a small proportion of women and will not substantially affect a board s performance. It is intended that this indicator will help to decrease the amount of time a woman has to wait to access advice or have the procedure once she has made her decision. Data Collection No additional data was required over and above that already collected in accordance with the 1967 Abortion Act. The data also are analysed by age and deprivation category to help identify inequalities in opportunities to access services due to poverty. 18
Baseline Data 2005 Table 3a Terminations 1 performed in Scotland Percentage of women having terminations at <10 weeks* gestation, by NHS Board of Residence, 2006 N H S board P erc entage Ayrshire & Arran 64.7 B orders 80.3 D um fries & G allow ay 65.4 Fife 70.3 Forth V alley 67.4 G ram pian 65.6 G reater G lasgow & C lyde 71.5 H ighland 64.4 Islands 2 64.4 Lanarkshire 51.5 Lothia n 67.4 Tayside 71.8 All Areas 67.3 *9 weeks and six days and under 1 Refers to therapeutic abortions notified in accordance with the Abortion Act 1967. 2 Orkney, Shetland and Western Isles NHS board areas. p Provisional. Source: Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967. Commentary In 2006 there were 13,081 terminations performed compared to 12,603 in 2005. This is consistent with the pattern seen in recent years. In 2006, the rate per 1,000 women aged 15 44 was 12.4, compared to 11.0 in 1997. The highest rates of termination per 1000 women aged 15 44 are in NHS Tayside 15.5, down from 16.4 in 2005. NHS Lothian 13.7, down from 14.1 NHS Grampian 12.6, down from 12.7 The lowest rates of termination were in Highland (9.9) and the Islands (6.1). The rate of terminations in most deprived (SIMD 5) areas was higher than in areas of low deprivation (SIMD 1) at 16.6 and 8.8 respectively. The use of medical methods continues to increase, with 66.4% of all terminations performed medically (at a gestation of 9 weeks or less) in 2006 compared 52.2 in 2000. 19
The proportion of early terminations has been relatively stable since 2000, with 67.3% of all terminations performed at less than 10 weeks in 2006. This has increased from 66.5% in 2005. NHS Lanarkshire has increased from 43.8 in 2005, to 51.5% in 2006 Figure 3a Percentage of terminations at <10 weeks* estimated gestation by NHS Board of Residence, 2006 Borders Tayside Greater Glasgow & Clyde Fife Lothian NHS board Forth Valley Scotland Grampian Dumfries & Galloway Ayrshire & Arran Highland Islands2 Lanarkshire 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 *9 weeks and six days and under 2 Orkney, Shetland and Western Isles NHS board areas. p Provisional. Source: Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967. Termination of Pregnancy by Age and Deprivation, 2006 The total number of terminations for all age groups increased steadily with increased levels of deprivation, from SIMD1 (1,843) to SIMD5 (3,736) (Table 3b and Figure 3b). This is up from 1,792 and 3,499 in 2005. % 20
Table 3b Terminations 1 performed to residents in Scotland, 2006 p, by deprivation, estimated gestation in weeks and age band. SIMD 2 1 SIMD 2 2 SIMD 2 3 SIMD 2 4 SIMD 2 5 All Scottish residents 3 <10 weeks Total % <10 weeks Total % <10 weeks Total % <10 weeks Total % <10 weeks Total % <10 weeks Total % <16 27 41 65.9 30 46 65.2 40 63 63.5 44 83 53.0 84 127 66.1 225 362 62.2 16 19 312 448 69.6 320 497 64.4 372 582 63.9 432 701 61.6 512 826 62.0 1 969 3 084 63.8 20 24 380 509 74.7 395 579 68.2 470 670 70.1 585 908 64.4 832 1 264 65.8 2 682 3 958 67.8 25 29 231 314 73.6 257 351 73.2 329 442 74.4 411 583 70.5 461 715 64.5 1 707 2 431 70.2 30 34 157 220 71.4 192 270 71.1 229 310 73.9 241 366 65.8 274 433 63.3 1 101 1 608 68.5 35 39 164 221 74.2 159 217 73.3 145 221 65.6 173 255 67.8 174 269 64.7 827 1 199 69.0 40+ 66 90 73.3 52 81 64.2 53 76 69.7 53 87 60.9 65 102 63.7 291 439 66.3 Grand Total 1 337 1 843 72.5 1 405 2 041 68.8 1 638 2 364 69.3 1 939 2 983 65.0 2 402 3 736 64.3 8 802 13 081 67.3 1 Refers to therapeutic abortions notified in accordance with the Abortion Act 1967. 2 Scottish index of multiple deprivation 3 Includes residents where deprivation is not known. p Provisional * Figures may not be the same as published on the ISD website due to an updated postcode file being used. Source: Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967. 21
Figure 3b Rate per 10,000 of total terminations for Scotland by deprivation category, 2006 40 35 30 Rate per 10 000 25 20 15 10 5 0 SIMD1 SIMD2 SIMD3 SIMD4 SIMD5 Deprivation Category SIMD5 represents 29% of the total terminations for Scotland, which is more than double that of SIMD1 and up 1% from 2005. The percentage of women pregnancies terminated at <10 weeks is lower for SIMD5 at 64.3% than SIMD1 at 72.5%. This repeats the pattern seen in 2005, which suggests a link between deprivation category and the proportion of women able to access termination services quickly and easily. Late presentation could be due to a number of reasons including: Poor or restricted service access Lack of information / education on how and where to access services Poor sexual health education (potentially leading to later presentation to services) Conclusion The inequalities notable in the 2005 data are present in 2006. This suggests the possibility that service access can be more limited in deprived areas. It should be considered, however, that in addition to poor service access and delayed referrals, social or cultural factors are also an issue to consider in regard to late presentation. NHS boards should ensure that there are no barriers in referral pathways that might prevent women from accessing services and examine discrepancies to ensure that all women are able to access termination services quickly and easily. It should be noted that small numbers might affect a board s performance in the data above. 22
HIV Therapy The proportion of HIV positive people in specialist care and eligible for antiretroviral therapy (ART) who have been treated and the proportion of those treated who have an undetectable viral load. The publication of the HIV therapy data has been delayed and will be available at a later date. Hepatitis B Vaccination for MSM The proportion of men who have sex with men (MSM) attending a GUM clinic and eligible for hepatitis B vaccine who receive their first dose in this setting. The hepatitis B data for calendar year 2007 will be published autumn 2008 due to changes in data collection methodology. Long Acting Reversible Methods of Contraception (LARC) The proportion of women of reproductive age using long acting reversible methods of contraception (LARC) in each NHS Board. The LARC data for 2007/2008 will be published in autumn 2008. The 2006/2007 LARC report can be accessed at www.isdscotland.org/kci. 23