Service Specification Chlamydia Screening Release: Final Date: 1 August 2010 Author: Steph Cook Head of Sexual Health Commissioning NHS Derby City Owner: Maureen Whittaker Associate Director of Public Health NHS Derbyshire County
Document Information Document location : This document is only valid on the day it was printed. Document source: Authorship: This document has been prepared by: Name Designation Organisation Steph Cook Head of Sexual Health Commissioning NHS Derby City Revision history: The current version of this document supersedes all previous versions. Revision date Summary of changes Version Approvals: This document requires the following approvals: Name Designation Signature Date of Issue Primary Care Programme Board Version Distribution: This document has been distributed to: Recipient Date of Issue Version
Date for Service Specification to be reviewed: Date of review Name Designation and Organisation Year 1 Year 2 Year 3
Contents: This should be in an automated format, to update.. Right click over the whole table and select - UPDATE WHOLE TABLE This will populate page numbers appropriately. Therefore it is advised that this table is updated as the final step before submission Section Page Document information 2 Purpose of this service specification template 4 document 1 Introduction 2 Definition of service 3 Overall aims 4 Key objectives 5 Key outcomes 6 National context 7 Local context, demographics, needs 8 Service outline 9 Model for the service pathways / interfaces 10 Client group served / eligibility / access criteria 11 Exclusions 12 Quality targets 13 Output and outcome measure requirements 14 Service monitoring, evaluation and review process / timescales 15 Workforce / staffing 16 Clinical and corporate governance 17 Policies / protocols / legal requirements 18 Appendices 19 References
1 Introduction: Sexual ill health has great human and economic costs. Chlamydia is the most common sexually transmitted infection (STI) diagnosed in genitourinary medicine (GUM) clinics in the United Kingdom 1 and affecting over 8% of screened General Practice populations in Chlamydia screening pilots 2. Infection is commonly asymptomatic (70% women and 50% men) and estimated that less than 10% are diagnosed. More than 1/3 of women found to have Chlamydia were diagnosed in primary care. The consequences of Chlamydial infection if untreated, accounts for significant longterm complications including pelvic inflammatory disease, ectopic pregnancy, tubal infertility and chronic abdominal pain 3. Primary Care services have the opportunity to offer convenient and accessible locations for the target group of 15 24 year olds who would not necessarily contact sexual health services for testing, to provide advice and information regarding Chlamydial infection and be able to offer them opportunistic screening. This service specification is designed to increase coverage for Chlamydia screening, specifically patients registered with General Practices. The advice and provision of Chlamydia screening will be delivered by General Practices through this Local Enhanced Service (LES) and integrated into the Derbyshire Chlamydia Screening Programme (DCSP) care pathway, in line with National Chlamydia Screening Programme (NCSP) guidance. 2 Definition of service: This LES is in relation to provision of opportunistic Chlamydia screening of asymptomatic people aged 15-24 only. Practices participating in this LES will be responsible for local promotion and raising awareness of the DCSP to encourage all registered young people aged 15-24 to accept the offer of an opportunistic Chlamydia screen (a self-administered first void urine test). 3 Overall aims: The aim of this service is to: Increase opportunistic Chlamydia screening uptake to 35% of the male and female population aged between 15-24 years inclusive. 1 Health Protection Agency, SCIEH, ISD, National Public Health Service for Wales, CDSC Northern Ireland, and UASSG. Renewing the focus. HIV and other sexually transmitted infections in the United Kingdom in 2002. London: Health Protection Agency, 2003. 2 Modelling the healthcare costs of an opportunistic Chlamydia screening programme. E J Adams, D S LaMontagne, A R Johnston, J M Pimenta, K A Fenton, W J Edmunds. Sex Transm Infect 2004; 80:363 370. doi: 10.1136/sti.2004.009654. 3 Department of Health Effective Commissioning of Sexual Health & HIV Services (Jan 2003).
Active promotion of the Derbyshire Chlamydia Screening Programme and importance of early diagnosis. Increase screening of asymptomatic patients within the age range consulting for unrelated conditions. Improve access for sexually active young men/women who do not use sexual health services. Reduce Chlamydia prevalence through increased early detection and treatment and thereby reduce transmission and associated complications. Raise general awareness of Chlamydia and other sexual health issues to promote safer sexual practice and good sexual health. Increase acceptability of testing for Chlamydia through non invasive testing techniques (urine samples for males and females). 4 Key objectives: The objectives of this service are to offer Chlamydia screening to men and women 15-24 years old inclusive, registered with General Practice by: Active promotion of the DCSP, through increased opportunistic screening. Encouraging people in the age range determined as being sexually active to accept a screen. Providing Chlamydia Screening kits and information. Supporting individuals to complete the test with explicit emphasis on the importance of return within specified time requirements and where possible encouraging use of on-site facilities (toilets) for individuals to take the test. Providing clear signposting and advice in relation to services and pathways patients will follow post screening. 5 Key outcomes: The key outcomes of the service are to: Improve access to Chlamydia screening across Derbyshire Increase Chlamydia screening uptake to 35% of young people aged 15-24 years Reduce Chlamydia prevalence among young people 6 National context: The Derbyshire Chlamydia Screening Programme is part of the National Chlamydia Screening Programme, a control and prevention programme targeted at sexually active young people under 25. Responsibility for the implementation and delivery of the programme lies with individual Primary Care Trusts (PCTs). The NCSP is delivered within 92 geographically distinct programme areas. All programme areas have a named programme lead; a Chlamydia screening co-ordinator based within a designated Chlamydia screening office (CSO) and a multidisciplinary local Chlamydia screening steering group. The CSO oversees all aspects of screening activity in their area.
The national Vital Signs Indicator (VSI) target for 2010-11 is for 35% of 15-24 year olds to be tested for Chlamydia. In Derbyshire this equates to 29,995 Chlamydia tests in 2010-11. 7 Local context, demographics, needs: Chlamydia is the most common sexually transmitted infection among young people in Derbyshire. In 2009, among attendees of Genitourinary Medicine (GUM) clinics in Derbyshire, Chlamydia affected around 700 individuals. In addition, many cases of STIs are diagnosed in other services, such as C&SH services, GP practices and termination of pregnancy services. In 2008-9 the Derbyshire Chlamydia Screening Programme identified 616 cases of Chlamydia among young people aged 15-24 years. Young people have been engaged in developing a local Chlamydia campaign to raise awareness of the need to get tested every year, and at each change of sexual partner. 8 Service outline: This LES is in relation to opportunistic Chlamydia screening of asymptomatic people aged 15-24 only. Clinical practice should not change as a result of this LES for any patients outside this age range, those presenting with symptoms and where there are reasons to carry out routine diagnostic tests. On such occasions the healthcare professional is required to test in the usual way. Practices will not be notified of results for any screens carried out as part of the DCSP, as all results notification and partner management will be done via the Chlamydia Screening Office (CSO). Where test results are required for symptomatic patients, or for other clinical reasons a diagnostic test must be carried out. Practices participating in this LES will be responsible for local promotion and raising awareness of the DCSP to encourage all registered young people aged 15-24 to accept the offer of an opportunistic Chlamydia screen. Practices signed up to this LES will be required to: Support individuals attending specifically for Chlamydia screening (e.g. by handing in a request card or through allocated collection points). The practice will be responsible for encouraging individuals to return the completed test Apply flagging mechanisms so patients attending the practice in the age range for unrelated conditions are identified and offered a Chlamydia screen. Include a routine Chlamydia screening for all individuals attending as part of the HPV programme. Include a routine Chlamydia screen with all contraception checks/advice for 15-24 year olds. Practices participating in this LES will offer routine Chlamydia screening in existing call initiatives such as, asthma checks, MMR vaccinations, and new patient checks.
Practices will raise awareness of the programme by informing patient at every opportunity when routine letters are sent out that they will be offered Chlamydia Screening to normalise the screening programme. This will enable screening to be offered when patients attend for routine appointments. The Practice will be responsible for ensuring a Chlamydia screen is offered to individuals in the age range at every opportunity at least annually and encourage a repeat screen with every change in sexual partner. The Chlamydia Screening kits are self explanatory and include everything the individual requires to complete the test themselves. Where additional advice/ clarity is required, practice staff (including nurses and receptionists) will be responsible for providing input to support successful completion of a test in a confidential and non judgmental manner Where an individual presents for a Chlamydia Screen who is under the age of 16, staff will ensure s/he is deemed competent to consent using the Fraser guidelines. Chlamydia screening is not offered to clients under 13 years old and the relevant Safeguarding procedures must be adhered to in all circumstances. The Chlamydia Screening Programme is not appropriate for pre IVF screening. Over 24 year olds requesting a Chlamydia test must not be included in the screening programme but offered a test using standard Chlamydia testing microbiology request forms. 9 Model for the service pathways / interfaces: The service will include the following elements: Offer screening through practice staff, including GPs, practice nurses, health care assistants and reception staff Allocate collection pick up points where individuals can collect kits anonymously without the need for a direct interaction with staff if preferred Staff with relevant knowledge of the programme and operating in an accessible, non-judgmental, client centred and confidential manner. Nominate a screening champion who will be the lead liaison for the DCSP within the practice. All promotional materials must be made prominently visible and available e.g. posters, leaflets and test request cards available in waiting areas and on TV/ electronic message displays. Routinely provide test request cards/information to the target population group, which can then be used by individuals to request a screening kit. Order and maintain supplies of screening kits and promotional materials provided by the Chlamydia Screening Office (CSO). Chlamydia screening kits must only be provided to 15-24 year olds for the purpose of the LES. Where an individual presents outside of the age range, a routine Chlamydia test should be offered and the sample sent with a standard
microbiology form, or the patient should be signposted to appropriate specialist services such as Contraception and Sexual Health or GUM services. Develop systems to identify registered individuals appropriate for screening and ensure proactive screening is offered and accepted. Encourage use of on-site facilities (access to toilets) so that individuals can take the test and return immediately. Any patient who cannot return their completed test immediately, for example because they have recently passed urine, can be given a postal kit to take away with them to complete a sample as soon is convenient. The importance of posting the sample through Royal Mail catching the last collection of the day Monday to Thursday i.e. enabling sample to be received at the laboratory within 24 hours of sample being taken must be highlighted to the individual. Ensure mandatory data requirements are collected on the test forms (e.g. patient postcode, client details for result notification i.e. mobile no, address etc) and that the relevant screening site code provided by the CSO is included on the form. Where postal kits are provided to patients the practice will need to ensure the site code is written on the test form in advance. Advice and support to clients will be provided through the provision of this service including advice on other Sexually Transmitted Infections, pathways for Chlamydia treatment and risk of re-infection, partner management, safer sex and condom use. Sample return and processing: Ensure samples are returned to Chesterfield Royal Hospitals NHS Foundation Trusts laboratory for processing, within the necessary specified timeframes to ensure samples are not compromised. Time in transit and Royal Mail collection and delivery times must be taken into consideration. Patients may request postal kits to take away with them and the importance of posting the sample direct to the Lab on the day taken must be emphasised. The information regarding postal issues between Fridays and Sundays and Bank Holidays must be reinforced to the individual. For screens completed within the practice, ensure each test taken is received at the Chesterfield Microbiology Lab for processing within 24 hours, if there are no facilities to keep samples refrigerated or within 96 hours if kept refrigerated. Patients may return postal kits to the practice, and the practice will ensure completed tests are returned for processing, by courier where there are existing links with the Chesterfield Lab or through the post within the timescales detailed above, if not. Interdependencies: The Chlamydia Screening Office (DCHS) will: 1. Be available to clarify any queries in relation to the DCSP 2. Provide training and support as required 3. Provision of all Derbyshire Chlamydia Screening Programme material including promotional material, posters, kits and test request cards.
4. Provide relevant information on Sexual Health services and patient pathways to enable appropriate signposting. 5. Provide ongoing support and direct liaison for all issues in relation to the programme. 6. Manage all results of screens through the CSO and organise treatment PN follow up for clients testing positive for Chlamydia The Practice will: 1. Ensure all aspects of the service outline and requirements detailed in this LES are met. 2. Nominate and provide contact details of a Chlamydia screening lead for the practice, who will act as the main point of contact for the CSO and PCT commissioners 3. Ensure the allocated screening site code (provided by the CSO) is written on all test request forms to ensure screens returned for processing can be identified to secure payment. 4. Ensure all screens completed are sent to the Chesterfield Lab for processing in line with the necessary requirements. 5. Participate in ongoing audit and evaluation. PCT Commissioners will: 1. Audit service provision to ensure effectiveness through performance monitoring arrangements (see section 13). 2. Ensure payment for services provided, subject to confirmed activity from the CSO. 10 Client group served / eligibility / access criteria: All asymptomatic sexually active young people aged between 15 and 24 years are eligible for a Chlamydia screening test. A diagnostic test should be taken instead of a screen if the young person has symptoms of an STI, if the individual requesting a screen is outside the target age range or a test is required for any clinical reason (eg prior to insertion of an IUD, before having a termination of pregnancy or before IVF treatment). 11 Quality targets: Consistent, high quality practice across all screening venues is fundamental to the success of the NCSP in achieving its aim of preventing and controlling Chlamydia infection. The National Chlamydia Screening Programme has quality assurance standards in place for diagnostics, notification of results, waiting time to treatment, partner notification and access to care. The practice is not directly responsible for delivering these quality standards, but can make a significant contribution to their achievement by: Ensuring samples are sent through to laboratory promptly Ensuring young people understand how to take the sample (first void urine)
Ensuring young people who have difficulty completing the form are assisted to do so, in particular ensuring contact details are clear Increasing the proportion of screens provided through GP practices 13 Output and outcome measure requirements: The Chlamydia Screening Office will provide information to Commissioners confirming the number of screens processed for each respective provider based on screening site code. CSO data on processed screens will be the information used to confirm payments. Quarterly monitoring data will also be provided to the practice to confirm activity, for information. In order to ensure activity is identified correctly to the relevant practice, it is crucial that the screening site code provided by the CSO is included on all forms. Without this code it will be impossible to confirm where the screen was generated and would have subsequent implications in terms of accurate payments being made. Activity data will be used to monitor progress and to identify where additional support/training may be necessary. The ongoing audit and evaluation of the programme is crucial to ensure a responsive programme is delivered that meets the needs of the population. The practice will be required to monitor distribution of kits and work towards an 80% conversion rate for the number of kits handed out compared to those returned as completed test. 14 Details of service monitoring, evaluation and review process / timescales: All monitoring will be co-ordinated through the Chlamydia Screening Office and the practice is not required to provide any monitoring data. Practices may wish to monitor their own progress and will be provided with quarterly data summarising their performance. 15 Workforce / staffing: The CSO staff will be available to provide dedicated operational briefings and detailed training/support to increase screening uptake as required Practices who have previously signed a LES will already have a supply of materials. For new screening sites all information required to commence screening will be distributed in advance. It will be the practice s responsibility to ensure ongoing supplies are maintained and ordered via the CSO. Materials provided by the programme include: Knowledge of the DCSP and wider sexual health issues. Clarity around pathways and procedures to be followed.
Supply of promotional materials and screening kits Information on the screening kits, test forms and other materials. Instructions on how to store and return completed kits for processing. Details in relation to positive client treatment and partner notification as managed by the CSO. Arrangements for re-ordering supplies. 16 Clinical and corporate governance: It is a condition of participation in this Locally Enhanced Service that practices will give notification, in addition to their statutory obligations, within 72 hours of the information becoming known to him/her, to the PCT clinical governance manager of all emergency admissions or harm/potential harm to patients under this service, where such events may be due to administration/usage of the drug(s) in question or attributable to the relevant underlying medical condition using the standard Incident Reporting form. Any Serious untoward incident must be reported to the Primary Care Clinical Quality Team within 24hours as per PCT Guidelines using the PCT`s incident reporting form. This is in addition to the practitioner s statutory obligations. All practices will be expected to be working towards registering with the Care Quality Commission and be compliant with the essential standards relating to quality and safety. 17 Policies / protocols / legal requirements: The service will be provided in line with the local guidance on Chlamydia Testing and Screening Management 4, Derbyshire Safeguarding arrangements and equality and diversity requirements. 18 Appendices: 1. Finance: This LES will commence from the 1 st August 2010 until 31 st March 2011. A signed copy of the agreement is required to confirm arrangements. The Practice will be expected to carry out Chlamydia screening for the respective registered sexually active 15-24 year old population. Note: The payments set out herein relate to the DCSP only and are not intended to change clinical practice required for routine diagnostic tests which should be managed in the usual way. Payment will be 7.00 per Chlamydia screen completed by a young person in the target age group, evidenced by a result being processed and received by the CSO (subject to inclusion of relevant GP site code ). Payment will be, subject to confirmation of related results processed by the CSO. To ensure all results are received and accounted for, payment will be made one month 4 JAPC (2010) Chlamydia Testing and Screening Management: A Framework for Derbyshire
following the end of the term of the agreement (30 th April or closest working day thereafter). 19 References: 1 Health Protection Agency, SCIEH, ISD, National Public Health Service for Wales, CDSC Northern Ireland, and UASSG. Renewing the focus. HIV and other sexually transmitted infections in the United Kingdom in 2002. London: Health Protection Agency, 2003. 2 Modelling the healthcare costs of an opportunistic Chlamydia screening programme. E J Adams, D S LaMontagne, A R Johnston, J M Pimenta, K A Fenton, W J Edmunds. Sex Transm Infect 2004; 80:363 370. doi: 10.1136/sti.2004.009654. 3 Department of Health Effective Commissioning of Sexual Health & HIV Services (Jan 2003). 4 JAPC (2010) Chlamydia Testing and Screening Management: A Framework for Derbyshire