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Contraceptive services for under 25s

About

What is covered

This interactive flowchart covers contraceptive services for under 25s.

Updates

Updates to this interactive flowchart

4 February 2019 Sexual health (NICE quality standard 178) added.
7 September 2016 Contraception (NICE quality standard 129) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on contraceptive services for under 25s in an interactive flowchart

What is covered

This interactive flowchart covers contraceptive services for under 25s.

Updates

Updates to this interactive flowchart

4 February 2019 Sexual health (NICE quality standard 178) added.
7 September 2016 Contraception (NICE quality standard 129) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Contraceptive services for under 25s (2014) NICE guideline PH51
Sexual health (2019) NICE quality standard 178
Contraception (2016) NICE quality standard 129

Quality standards

Contraception

These quality statements are taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statements

Contraceptive information and methods

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women asking for contraception from contraceptive services are given information about, and offered a choice of, all methods including long-acting reversible contraception.

Rationale

Offering information about the full range of contraceptives available, including long-acting reversible contraception, will ensure women asking for routine or emergency contraception can make an informed choice. Helping women choose the method of contraception that suits them best, and increasing their awareness of how to use contraceptives effectively, will help to reduce unplanned pregnancies.

Quality measures

Structure
a) Evidence that accessible information is available about the full range of contraceptive methods, including long-acting reversible contraception, and the local services that provide them.
Data source: Local data collection.
b) Evidence of local processes and referral pathways to ensure that women asking for contraception from contraceptive services are given information about, and offered a choice of, all methods including long-acting reversible contraception.
Data source: Local data collection.
Process
a) Proportion of women who ask for contraception from contraceptive services who are given information about all methods, including long-acting reversible contraception.
Numerator – the number in the denominator who are given information about all methods, including long-acting reversible contraception.
Denominator – the number of women who ask for contraception from contraceptive services.
Data source: Local data collection.
b) Proportion of women who ask for contraception from contraceptive services who are offered a choice of all contraceptive methods, including long-acting reversible contraception.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods, including long-acting reversible contraception.
Denominator – the number of women who ask for contraception from contraceptive services.
Data source: Local data collection.
Outcome
a) Contraceptive use in women.
Data source: Local data collection.
b) Uptake of long-acting reversible contraception.
Data source: Local data collection.
c) Women’s satisfaction with their choice of contraceptive method.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (including GPs, community pharmacies and sexual and reproductive health services) ensure that processes are in place to offer women information about, and a choice of, all contraceptive methods, including long-acting reversible contraception. Service providers work together so that they can refer women to a suitable alternative service if they cannot provide the preferred method of contraception.
Healthcare practitioners (including GPs, community pharmacists, sexual and reproductive health consultants and nurses) ensure that they give women who ask for contraception information about, and a choice of, all contraceptive methods, including long-acting reversible contraception. If they cannot provide the woman’s preferred method of contraception they refer them to a suitable alternative service.
Commissioners (clinical commissioning groups, local authorities and NHS England) commission contraceptive services that provide information on all contraceptive methods, including long-acting reversible contraception, and offer all contraceptive methods to all women. Commissioners ensure providers work together to ensure women are provided with their preferred method of contraception.

What the quality statement means for women attending contraceptive services

Women attending a contraceptive service are offered a choice of all contraceptive methods, including long-acting reversible contraception, and the information they need to decide which method is suitable for them. If the service cannot provide their preferred method of contraception they tell them where they can get it from.

Source guidance

Definitions of terms used in this quality statement

Contraceptive services
Contraceptive services include those offered in education, GP services, pharmacies, maternity and postnatal care services, walk-in centres, acute and emergency care, and the voluntary and private sectors. This includes open access contraceptive services that are available to everyone and provide walk in and appointment clinics.
[NICE’s guideline on contraceptive services for under 25s, recommendation 3 and expert opinion]
Information about contraceptive methods
This information covers all contraceptive methods and includes:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and intrauterine devices)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
[Adapted from NICE’s guideline on long-acting reversible contraception and expert opinion]
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
[Adapted from NICE’s guideline on long-acting reversible contraception]
Methods that depend on the person remembering to take or use them. These include:
  • contraceptive vaginal ring
  • contraceptive patch
  • combined oral contraceptive pill
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • natural family planning.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Contraceptive options may be limited for women with a learning disability or cognitive impairment. Contraceptive services should make it clear to women why specific methods cannot be offered to them.
Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information about all methods and allow the woman to choose the one that suits her best.
If a healthcare practitioner‘s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Emergency contraception

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women asking for emergency contraception are told that an intrauterine device is more effective than an oral method.

Rationale

An intrauterine device (IUD) has a lower failure rate than oral methods of emergency contraception. Also, once in place, it can be used on an ongoing basis. If women use an IUD this will reduce the risk of unplanned pregnancies and avoid the need for emergency contraception. If a woman chooses to have an IUD as a form of emergency contraception, but the healthcare practitioner cannot fit it there and then, they should direct the woman to a suitable service and give her an oral method in the interim.

Quality measures

Structure
Evidence of local processes to ensure that women asking for emergency contraception are told that an intrauterine device is more effective than an oral method.
Data source: Local data collection.
Process
Proportion of requests for emergency contraception where the woman is told that an intrauterine device is more effective than an oral method.
Numerator – the number in the denominator where the woman is told that an intrauterine device is more effective than an oral method.
Denominator – the number of requests for emergency contraception.
Data source: Local data collection. Quality and Outcomes Framework indicator CON003 captures data on the provision of information about long-acting reversible methods of contraception to women who are prescribed emergency hormonal contraception by their GP.
Outcome
a) Intrauterine device use as an emergency contraceptive.
Data source: Local data collection. The Health and Social Care Information Centre’s Sexual and Reproductive Health Activity Dataset includes information on methods of contraception for people using dedicated sexual and reproductive health services.
b) Abortion rate.
Data source: Local data collection. The Department of Health’s Abortion statistics can be analysed geographically.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (including GPs, community pharmacies and sexual and reproductive health services) ensure that protocols and procedures are in place to tell women asking for emergency contraception that an IUD is more effective than an oral method. Service providers ensure that rapid referral pathways are in place for women who choose an emergency IUD if they are not able to fit one immediately. Service providers also ensure that protocols are in place to offer them an oral emergency method in the interim.
Healthcare practitioners (including GPs, community pharmacists, sexual health consultants and nurses) tell women who ask for emergency contraception that an IUD is more effective than an oral method. Practitioners unable to fit IUDs at presentation refer women to a service that can and offer them an oral emergency method in the interim.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that services providing emergency contraception tell women that an IUD is more effective than an oral method. Commissioners ensure that referral pathways are in place for women who choose to have an emergency IUD fitted if the service cannot provide this on presentation, and that the service offers an oral emergency method in the interim.

What the quality statement means for women

Women asking for emergency contraception are told that an intrauterine device (IUD, also known as the coil) is more effective than an oral method (an emergency pill) and can also be used as a long-term method of contraception.

Source guidance

Definitions of terms used in this quality statement

Emergency contraception
If a woman has had sex without using contraception, or thinks that her contraception did not work, an emergency contraceptive can be used. There are 3 different types:
  • emergency contraceptive pill, levonorgestrel 1.5 mg
  • emergency contraceptive pill, ulipristal acetate 30 mg
  • emergency intrauterine device.
Both emergency contraceptive pills are also referred to as the ‘morning after pill’.
[Adapted from Emergency contraception (Faculty of Sexual & Reproductive Healthcare)]
Intrauterine device
Also referred to as an IUD or coil, this is a small, T-shaped copper device that is inserted in the uterus. It has 1 or 2 threads on the end that hang through the entrance of the uterus (the cervix).
[Adapted from Intrauterine contraception (Faculty of Sexual & Reproductive Healthcare)]

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information and allow the woman to choose the one that suits her best.
If a healthcare practitioner‘s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Contraception after an abortion

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women who request an abortion discuss contraception with a healthcare practitioner and are offered a choice of all methods when they are assessed for abortion and before discharge.

Rationale

Ensuring women can make an informed choice about contraception following an abortion will reduce the risk of future unplanned pregnancies. Having the opportunity to discuss contraception when they are being assessed for an abortion will give them time to consider all the options. Further discussion before discharge from the abortion service can help ensure timely access to contraception.

Quality measures

Structure
a) Evidence of local processes to ensure that women discuss contraception and all contraceptive methods with a healthcare practitioner when being assessed for an abortion.
Data source: Local data collection.
b) Evidence of local processes to ensure that a healthcare practitioner offers women a choice of all contraceptive methods before discharge from an abortion service.
Data source: Local data collection.
Process
a) Proportion of women who discuss contraception and all contraceptive methods with a healthcare practitioner at an assessment for abortion.
Numerator – the number in the denominator who discuss contraception and all contraceptive methods with a healthcare practitioner.
Denominator – the number of women having an assessment for abortion.
Data source: Local data collection.
b) Proportion of women who are offered a choice of all contraceptive methods before discharge from an abortion service.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods before discharge.
Denominator – the number of women discharged from an abortion service.
Data source: Local data collection.
Outcome
a) Uptake of long-acting reversible contraception at the time of abortion.
Data source: Local data collection.
b) Contraception uptake rate after abortion.
Data source: Local data collection.
c) Women who have more than 1 abortion.
Data source: Local data collection. The Department of Health’s Abortion statistics include data on repeat abortions.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (including secondary care, community genitourinary medical and private sector services) establish protocols to ensure that healthcare practitioners discuss contraception and all contraceptive methods with women at their assessment for abortion and before discharge. Service providers offer women a choice of all contraceptive methods before discharge. If contraceptives are not provided at discharge, service providers ensure that referral pathways to a contraceptive service are in place.
Healthcare practitioners (including GPs, hospital doctors and nurses) discuss contraception and all contraceptive methods with women at their assessment for an abortion and before discharge. Healthcare practitioners offer women a choice of all contraceptive methods before discharge. If contraceptives are not provided at discharge, they offer to refer women to a contraceptive service.
Commissioners (clinical commissioning groups) ensure that abortion services discuss contraception and all contraceptive methods with women at their assessment for an abortion and before discharge. Commissioners ensure that abortion services offer women a choice of all contraceptive methods before discharge, or offer a referral to a contraceptive service if contraceptives are not provided. Commissioners could consider a local performance indicator for abortion services to improve uptake of contraception at discharge.

What the quality statement means for women

Women who plan to have an abortion are offered the chance to discuss contraception with a healthcare practitioner during assessment for their abortion and again before they are discharged. They are offered a choice of all contraceptive methods before they are discharged or referral to a contraceptive service if contraception is not provided.

Source guidance

Definitions of terms used in this quality statement

Discussion about contraception
When discussing contraception, emphasise that women are fertile immediately after an abortion and give details of all contraceptive methods including:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and IUDs)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
[Adapted from NICE’s guidelines on contraceptive services for under 25s and long-acting reversible contraception and expert opinion]
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
[Adapted from NICE’s guideline on long-acting reversible contraception ]
Methods that depend on the person remembering to take or use them. These include:
  • contraceptive vaginal ring
  • contraceptive patch
  • combined oral contraceptive pill
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • natural family planning.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.
[Adapted from the Faculty of Sexual & Reproductive Healthcare guidelines on barrier methods for contraception and STI prevention, fertility awareness methods, progestogen-only pills and combined hormonal contraception]

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information about all methods and allow the woman to choose the one that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Contraception after childbirth

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women who give birth are given information about, and offered a choice of, all contraceptive methods by their midwife within 7 days of delivery.

Rationale

Supporting women to make an informed choice about contraception after childbirth will reduce the risk of future unplanned pregnancies. Advice and information should be given as soon as possible after delivery because fertility may return quickly, including in women who are breastfeeding. Providing advice about contraception after childbirth also helps avoid the risk of complications associated with an interpregnancy interval of less than 12 months.

Quality measures

Structure
a) Evidence of local processes to ensure that women who give birth are given information about all contraceptive methods by their midwife within 7 days of delivery.
Data source: Local data collection.
b) Evidence of local processes and referral pathways to ensure that women who give birth are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Data source: Local data collection.
Process
a) Proportion of women who give birth who are given information about all contraceptive methods by their midwife within 7 days of delivery.
Numerator – the number in the denominator who are given information about all contraceptive methods by their midwife within 7 days of delivery.
Denominator – the number of women who give birth.
Data source: Local data collection.
b) Proportion of women who give birth who are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Denominator – the number of women who give birth.
Data source: Local data collection.
Outcome
a) Satisfaction with advice about contraceptive methods after childbirth.
Data source: Local data collection.
b) Contraception uptake rates in women who have given birth.
Data source: Local data collection.
c) Women who have a short interpregnancy interval.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (secondary care and community maternity services) establish protocols to ensure that midwives give women information about all contraceptive methods, and offer them a choice of all methods, within 7 days of delivery. Service providers ensure women are referred to a contraceptive service if their chosen contraceptive cannot be provided immediately.
Healthcare practitioners (midwives) give women information about, and offer them a choice of all contraceptive methods within 7 days of delivery. Midwives refer women to a contraceptive service if their chosen contraceptive cannot be provided immediately.
Commissioners (clinical commissioning groups) ensure that maternity services give women information about, and offer them a choice of all contraceptive methods within 7 days of delivery, and refer them to a contraceptive service if contraception cannot be provided immediately.

What the quality statement means for women

Women who give birth are offered a choice of all contraceptive methods and given the information they need to decide which method is suitable for them by their midwife. This happens within a week of delivery. The midwife tells them how to get their chosen contraceptive.

Source guidance

Definitions of terms used in this quality statement

Information about contraceptive methods
Information covers all contraceptive methods and includes:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and intrauterine devices)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
[Adapted from NICE’s guideline on long-acting reversible contraception and expert opinion]
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
[Adapted from NICE’s guideline on long-acting reversible contraception]
Methods that depend on the person remembering to take or use them. These include:
  • contraceptive vaginal ring
  • contraceptive patch
  • combined oral contraceptive pill
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • natural family planning.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception healthcare practitioners should give information about all methods and allow the woman to choose the method that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Asking people about their sexual history

This quality statement is taken from the sexual health quality standard. The quality standard defines clinical best practice for sexual health and should be read in full.

Quality statement

People are asked about their sexual history at key points of contact.

Rationale

Asking people about their sexual history enables healthcare professionals to identify if they are at risk of sexually transmitted infections (STIs) and ensures that they can be given information and support to prevent infection. It can also help local services to understand the needs of their populations.

Quality measures

Structure
a) Evidence of local agreement on the key points of contact when people will be asked about their sexual history.
Data source: Local data collection, such as service protocols.
b) Evidence of local processes to ensure that people are asked about their sexual history at key points of contact.
Data source: Local data collection, such as service protocols.
Process
Proportion of people who have a discussion about their sexual history at key points of contact.
Numerator – the number in the denominator who have a discussion about their sexual history.
Denominator – the number of people attending a key point of contact.
Data source: Local data collection. Documenting that a discussion has taken place could form part of an electronic health record.
Outcome
Coverage of testing for STIs: proportion of people attending the service who are tested for STIs.
Data source: Local data collection, for example, the proportion of young people screened for chlamydia and HIV testing coverage is collected as part of Public Health England’s Sexual and reproductive health profiles.

What the quality statement means for different audiences

Service providers (such as primary care services, contraceptive services, genitourinary medicine clinics, abortion services, community sexual health services, and voluntary and community organisations) ensure processes are in place and staff are trained to ask people about their sexual history in a sensitive and supportive way at key points of contact. Service providers can help staff to ensure sexual history taking becomes routine by providing tools such as self-completion checklists.
Healthcare professionals (such as GPs, midwives, nurses, doctors, and drug and alcohol workers) ask people about their sexual history at key points of contact. Healthcare professionals ensure that they discuss sexual history in a sensitive and supportive way.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services that identify people who are at risk of STIs by asking them about their sexual history at key points of contact. Commissioners agree key points of contact when people should be asked about their sexual history with service providers. Commissioners ensure that services that engage with people who are less likely to attend primary care or sexual health services are included.
People using healthcare services are asked about their sexual history, for example, the gender of their last partner and their use of condoms, when they attend relevant appointments. This will ensure that they are given the support they need if they are at risk of getting an STI.

Source guidance

Definitions of terms used in this quality statement

Key points of contact
Key points of contact could be consultations:
  • with newly registered patients
  • about contraception, pregnancy (including planning a pregnancy), abortion, alcohol or substance misuse
  • when carrying out a cervical smear test, offering an STI test, or providing travel immunisation.
Asking about sexual history
Services may take a brief core sexual history to establish whether someone is at any risk of STIs and then take a more detailed history if the screen is positive. A more detailed sexual history should include:
  • the gender of sexual partner(s)
  • the type of sexual contact/sites of exposure (oral, vaginal, anal)
  • condom use/barrier use (and whether properly used)
  • relationship with the partner (for example, live-in, regular or casual partner), duration of the relationship and whether the partner could be contacted
  • the time interval since the last sexual contact
  • any symptoms or any risk factors for blood-borne viruses in the partner including known or suspected STIs, injecting drug use, previous homosexual sex (for male partners) and any other risk of sexual infection.
[Adapted from the British Association of Sexual Health and HIV’s UK national guideline for consultations requiring sexual history taking, recommendation 3.3.1]

Equality and diversity considerations

When asking people about their sexual history, be aware that they may have additional needs such as physical, sensory or learning disabilities, and that they may not speak or read English, or may have reduced literacy skills. People should have access to an interpreter or advocate if needed.
Healthcare professionals should ensure that older people are asked about their sexual history in order to identify if they are at risk of STIs. Healthcare professionals should also be trained to identify and respond to the specific needs of lesbian, gay, bisexual, and transgender people when asking about their sexual history.
Safeguarding links should be in place with all services that may engage with young people and vulnerable adults about their sexual health. Services should be clear what action should be taken if concerns are raised about child sexual exploitation or abuse, female genital mutilation, human trafficking or modern slavery.

Discussing prevention and testing with people who are at risk of sexually transmitted infections

This quality statement is taken from the sexual health quality standard. The quality standard defines clinical best practice for sexual health and should be read in full.

Quality statement

People identified as being at risk of sexually transmitted infections have a discussion about prevention and testing.

Rationale

Discussing how to prevent and be tested for sexually transmitted infections (STIs) can increase opportunities for testing and harm reduction. A structured discussion can help identify and reduce behaviours that put a person at risk of STIs.

Quality measures

Structure
a) Evidence of local arrangements to ensure that trained healthcare professionals are available to discuss behaviour change with people identified as being at risk of STIs.
Data source: Local data collection, such as training records and staff rotas.
b) Evidence of local processes to ensure that people identified as being at risk of STIs have a discussion about prevention and testing.
Data source: Local data collection, such as service protocols.
Process
Proportion of people identified as being at risk of STIs who have a discussion about prevention and testing.
Numerator – the number in the denominator who have a discussion about prevention and testing.
Denominator – the number of people identified as being at risk of STIs.
Data source: Local data collection. Documenting that a discussion has taken place could form part of an electronic health record.
Outcome
a) Coverage of testing for STIs: proportion of people attending the service who are tested for STIs.
Data source: Local data collection, for example, the proportion of young people screened for chlamydia and HIV testing coverage are collected as part of Public Health England’s Sexual and reproductive health profiles.
b) New STI diagnoses (excluding chlamydia in people aged under 25) per 100,000 people aged 15 to 64.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.
c) Chlamydia detection rate per 100,000 people aged 15 to 24.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.

What the quality statement means for different audiences

Service providers (such as primary care services, contraceptive services, genitourinary medicine clinics and community sexual health services) ensure that they have healthcare professionals trained in sexual health who discuss the prevention of and testing for STIs with people identified as being at risk. Service providers should ensure that healthcare professionals signpost people at risk to high-quality supporting information and services, including online sexual health services.
Healthcare professionals (such as GPs, midwives, practice nurses and doctors who work in sexual health services) have one-to-one structured discussions with people identified as being at risk of STIs about how they can reduce their risk and how to get tested. Healthcare professionals should signpost people at risk to high-quality supporting information and services, including online sexual health services.
Commissioners (clinical commissioning groups, local authorities and NHS England) work together to ensure that they commission a range of services that provide information on the prevention of and testing for STIs to people identified as being at risk. Commissioners ensure that services that engage with people who are less likely to attend primary care or sexual health services are included.
People who are at risk of getting an STI talk to their healthcare professional about how to prevent STIs. They should also be given information about how to get tested for STIs and where to get further advice.

Source guidance

Definitions of terms used in this quality statement

Discussion about prevention and testing
Discussions should be structured on the basis of behaviour change theories. They should address factors that can help reduce risk taking and improve self-efficacy and motivation. Ideally, each session should last at least 15 to 20 minutes. The number of sessions will depend on individual need.
People at risk of sexually transmitted infections
This includes the following key groups and behaviours:
  • men who have sex with men
  • people who have come from or who have visited areas of high HIV prevalence
  • people who misuse alcohol or substances, or both
  • people who have early onset of sexual activity
  • people who have condomless sex and frequently change or have multiple sexual partners.

Equality and diversity considerations

A discussion about prevention and testing for STIs should be age appropriate and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English, or who have reduced literacy skills. People should have access to an interpreter or advocate if needed.
Healthcare professionals should be trained to identify and respond to the specific needs of lesbian, gay, bisexual, and transgender people when discussing prevention and testing for STIs.

Condom distribution schemes

This quality statement is taken from the sexual health quality standard. The quality standard defines clinical best practice for sexual health and should be read in full.

Quality statement

Local authorities provide a range of condom distribution schemes tailored to the needs of their populations.

Rationale

Providing a variety of condom distribution schemes ensures that different populations, including those most at risk of sexually transmitted infections (STIs), can access a scheme that will meet their needs. Condom schemes should be provided alongside existing services that are likely to be used by people most at risk of getting an STI. This can increase rates of condom use and reduce STI rates.

Quality measures

Structure
a) Evidence of local arrangements to assess the needs of local populations for condom distribution schemes.
Data source: Local data collection, such as needs assessments based on consultation and STI rates.
b) Evidence of local arrangements to provide a range of condom distribution schemes tailored to the needs of the population.
Data source: Local data collection, such as service specifications for a mix of different types of condom distribution scheme.
c) Evidence of local arrangements to publicise condom distribution schemes to people most at risk of getting an STI.
Data source: Local data collection, such as posters, leaflets and social media campaigns.
Outcome
a) Proportion of people who are at risk of STIs who used a condom at last intercourse.
Data source: Local data collection, such as a survey of young people or other groups at risk of STIs.
b) New STI diagnoses (excluding chlamydia in people aged under 25) per 100,000 people aged 15 to 64.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.
c) Chlamydia detection rate per 100,000 people aged 15 to 24.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.

What the quality statement means for different audiences

Service providers (voluntary sector services, school health services and primary healthcare services) provide a range of condom distribution schemes tailored to the needs of different local populations. Service providers publicise condom schemes to people most at risk of getting an STI. Service providers also ensure that referral pathways are in place to other services to meet the needs of those using the service.
Healthcare professionals (such as GPs, practice nurses, pharmacists and sexual health consultants) are aware of condom distribution schemes and tell people who are at risk of getting an STI how to access them.
Commissioners (local authorities) ensure that they commission a mix of different types of condom distribution schemes tailored to the needs of the population, including multicomponent schemes, single-component schemes (free condoms) and cost-price sales schemes. Commissioners should commission tailored multicomponent condom schemes in preference to other types of condom scheme for young people aged under 16. Commissioners ensure there are links between condom schemes and local sexual and reproductive health services.
People at risk of getting an STI are made aware of where they can get condoms.

Source guidance

Sexually transmitted infections: condom distribution schemes (2017) NICE guideline NG68, recommendation 1.1.1

Definitions of terms used in this quality statement

Condom distribution schemes
These are usually referred to as 'condom schemes'. The term refers to all schemes that provide free or cost-price condoms, female condoms and dental dams, with or without lubricant. Schemes also offer advice, information or support. They include:
  • Cost-price sales schemes that provide cost-price condoms and, if appropriate, lubricant. They include community schemes that provide cost-price condoms to sex workers and online services.
  • Multicomponent schemes (such as C-card) that distribute free condoms with or without lubricant, together with training, information or other support.
  • Single-component schemes that provide or distribute free condoms and if appropriate, lubricant. This includes online services for specific groups or areas of the country, and distribution schemes in public places.
[NICE’s guideline on sexually transmitted infections: condom distribution schemes, terms used in this guideline]

Equality and diversity considerations

Condom schemes should be accessible for young people including those who use public transport.
Safeguarding links should be in place with all services that may engage with young people and vulnerable adults about their sexual health. Services should be clear what action should be taken if concerns are raised about child sexual exploitation or abuse, female genital mutilation, human trafficking or modern slavery.

Access to sexual health services

This quality statement is taken from the sexual health quality standard. The quality standard defines clinical best practice for sexual health and should be read in full.

Quality statement

People contacting a sexual health service about a sexually transmitted infection are offered an appointment that is within 2 working days.

Rationale

Prompt access to sexual health services will promote good sexual health and reduce sexual health inequalities. Ensuring people are offered quick and easy access to support can help to reduce the likelihood of onward transmission of sexually transmitted infections (STIs), ensuring that tests and interventions can be provided to reduce health complications. If walk-in clinics are provided there should be reasonable waiting times to encourage people to use the service.

Quality measures

Structure
Evidence of local arrangements to ensure that people contacting a sexual health service about an STI are offered an appointment that is within 2 working days.
Data source: Local data collection, such as service protocols. Included in the Department of Health and Social Care’s Integrated sexual health services: a suggested national service specification.
Process
a) Proportion of contacts with a sexual health service about an STI in which an appointment that is within 2 working days, was offered.
Numerator – the number in the denominator in which an appointment that is within 2 working days, was offered.
Denominator – the number of contacts with a sexual health service about an STI.
Data source: Local data collection, such as an audit of patient health records. Included in the Department of Health and Social Care’s Integrated sexual health services: national service specification.
b) Proportion of attendances at a sexual health service walk-in clinic in which the waiting time was less than 2 hours.
Numerator – the number in the denominator in which the waiting time was less than 2 hours.
Denominator – the number of attendances at a sexual health service walk-in clinic.
Data source: Local data collection, such as clinic wait time records. Included in the Department of Health and Social Care’s Integrated sexual health services: national service specification.
Outcome
a) Satisfaction with access to services among people who contact sexual health services about an STI.
Data source: Local data collection, such as a patient survey.
b) Coverage of testing for STIs: proportion of people attending the service who are tested for STIs.
Data source: Local data collection, for example, the proportion of young people screened for chlamydia and HIV testing coverage are collected as part of Public Health England’s Sexual and reproductive health profiles.
c) New STI diagnoses (excluding chlamydia in people aged under 25) per 100,000 people aged 15 to 64.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.
d) Chlamydia detection rate per 100,000 people aged 15 to 24.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.

What the quality statement means for different audiences

Service providers (sexual health services) ensure that they offer people who contact the service about an STI either an appointment or the option to attend a walk-in clinic, which is within 2 working days. Service providers ensure that walk-in clinics are sufficiently resourced so that waiting times are less than 2 hours. Providers should offer a mix of timed appointments and walk-in clinics to meet the needs of the local population.
Healthcare professionals who work in sexual health services offer people contacting the service about an STI either an appointment or the option to attend a walk-in clinic, which is within 2 working days.
Commissioners (local authorities) commission sexual health services with sufficient capacity to ensure that people contacting the service about an STI are offered either an appointment or the option to attend a walk-in clinic, which is within 2 working days, and monitor waiting times.
People who contact a sexual health service about an STI are offered either an appointment or attendance at a walk-in clinic within 2 working days. If they go to a walk-in clinic they wait no longer than 2 hours.

Source guidance

Definitions of terms used in this quality statement

Sexual health services
Sexual health services include arrangements for the notification, testing, treatment and follow-up of partners of people who have an STI (partner notification).
The service should be delivered in accordance with the level 1, 2 and 3 service model. It does not include self-managed care such as home remote sampling and test kits accessed via online services.
An appointment
A scheduled time at a clinic or the option to attend a walk-in clinic.
[Expert opinion]

Equality and diversity considerations

Services should make reasonable adjustments to ensure that people with additional needs such as physical, sensory or learning disabilities, and people who do not speak or read English, or who have reduced literacy skills, can contact sexual health services to make appointments. People should have access to an interpreter or advocate if needed.
Sexual health services should be accessible for young people including those who use public transport.

Partner notification

This quality statement is taken from the sexual health quality standard. The quality standard defines clinical best practice for sexual health and should be read in full.

Quality statement

People diagnosed with a sexually transmitted infection are supported to notify their partners.

Rationale

Supporting people who have been diagnosed with a sexually transmitted infection (STI) to notify their partners can help to prevent reinfection and reduce the transmission of STIs. It can also ensure that their partners are tested, and if necessary treated, as soon as possible to prevent health complications.

Quality measures

Structure
a) Evidence of local arrangements for partner notification to be discussed with people diagnosed with STIs.
Data source: Local data collection, such as service protocols. Included in the Department of Health and Social Care’s Integrated sexual health services: national service specification.
b) Evidence of local arrangements for partner notification support to be provided to people diagnosed with STIs.
Data source: Local data collection, such as service protocols and referral pathways. Included in the Department of Health and Social Care’s Integrated sexual health services: national service specification.
Process
Proportion of people diagnosed with an STI who have partner notification initiated.
Numerator – the number in the denominator who have partner notification initiated.
Denominator – the number of people diagnosed with an STI.
Data source: Local data collection. Public Health England’s GUMCAD STI surveillance system collects data on partner notification being initiated.
Outcome
a) Coverage of testing for STIs: proportion of people attending the service who are tested for STIs.
Data source: Local data collection, for example, the proportion of young people screened for chlamydia and HIV testing coverage, are collected as part of Public Health England’s Sexual and reproductive health profiles.
b) Number of people presenting as a partner of an index case diagnosed with an STI.
Data source: Local data collection. Public Health England’s GUMCAD STI surveillance system collects data on people presenting as a partner of a person identified as having an index case of chlamydia, gonorrhoea, HIV or non-specific genital infection.

What the quality statement means for different audiences

Service providers (such as primary care services, genitourinary medicine clinics and community health services) ensure that processes are in place for discussions about partner notification to take place when people are diagnosed with an STI. Service providers ensure that they have clear partner notification procedures in place, including referral pathways to specialist providers, so that people can be supported to notify their partners.
Healthcare professionals (such as GPs, practice nurses and sexual health consultants) ensure they are aware of local partner notification procedures and provide support to people diagnosed with an STI to notify their partners. Partner notification may be undertaken by the healthcare professional or the person diagnosed with an STI and may require referral to a specialist service.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services that support people who are diagnosed with an STI to notify their partners. Commissioners ensure that the roles and responsibilities of different services in relation to partner notification are clear and that referral pathways are in place. Commissioners regularly monitor and review the overall effectiveness of local partner notification procedures.
People diagnosed with an STI are given encouragement and support from a healthcare professional to tell their partners about the STI. This will help partners to get tested as soon as possible and to receive treatment if they are also infected.

Source guidance

Definitions of terms used in this quality statement

Support to notify their partners
Partner notification procedures should be in place to provide support to contact, test and treat partners of people diagnosed with an STI. The support provided should be tailored to meet the individual’s needs and if necessary people should be referred to a specialist with responsibility for partner notification. Partner notification may be undertaken by the healthcare professional or the person diagnosed with an STI.

Equality and diversity considerations

Services to support people to notify their partners about an STI should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English, or who have reduced literacy skills. People should have access to an interpreter or advocate if needed.

Repeat testing for sexually transmitted infections

This quality statement is taken from the sexual health quality standard. The quality standard defines clinical best practice for sexual health and should be read in full.

Quality statement

Men who have sex with men have repeat testing every 3 months if they are at increased risk of sexually transmitted infections.

Rationale

Regular repeat testing for sexually transmitted infections (STIs) for men who have sex with men and who are at increased risk of STIs will ensure that diagnosis is made as soon as possible and further transmission of STIs can be avoided.

Quality measures

Structure
a) Evidence of local arrangements to provide STI repeat testing every 3 months for men who have sex with men and are at increased risk of STIs.
Data source: Local data collection, such as service protocols.
b) Evidence of local arrangements to encourage men who have sex with men to have repeat STI tests every 3 months if they are at increased risk of STIs.
Data source: Local data collection, such as health promotion leaflets and materials.
Process
a) Proportion of men who have sex with men and are at increased risk of STIs who were sent a reminder to have repeat testing for STIs within the past 3 months.
Numerator – the number in the denominator who were sent a reminder to have repeat testing for STIs within the past 3 months.
Denominator – the number of men who have sex with men and are at increased risk of STIs.
Data source: Local data collection, such as an audit of patient health records.
b) Proportion of men who have sex with men and are at increased risk of STIs who were tested for STIs within the past 3 months.
Numerator – the number in the denominator who were tested for STIs within the past 3 months.
Denominator – the number of men who have sex with men and are at increased risk of STIs.
Data source: Local data collection, such as an audit of patient health records.
Outcome
a) Coverage of testing for STIs: proportion of people attending the service who are tested for STIs.
Data source: Local data collection, for example, the proportion of young people screened for chlamydia and HIV testing coverage are collected as part of Public Health England’s Sexual and reproductive health profiles.
b) New STI diagnoses (excluding chlamydia in people aged under 25) per 100,000 people aged 15 to 64.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.
c) Chlamydia detection rate per 100,000 people aged 15 to 24.
Data source: These data are collected as part of Public Health England’s Sexual and reproductive health profiles.

What the quality statement means for different audiences

Service providers (such as primary care services, genitourinary medicine clinics, community sexual health services and online sexual health services) offer men who have sex with men repeat STI testing every 3 months if they are at increased risk of STIs. Service providers ensure men are signposted to an alternative service for repeat testing if necessary. They ensure that recall reminders are sent every 3 months to improve re-attendance rates.
Healthcare professionals (such as GPs, practice nurses and sexual health consultants) offer men who have sex with men repeat appointments for STI testing every 3 months if they are at increased risk of STIs. If their service does not provide repeat testing, healthcare professionals should signpost the person to an alternative service.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services that arrange repeat appointments for STI testing every 3 months for men who have sex with men and are at increased risk of STIs. This could include online sexual health services.
Men who have sex with men and who have a high risk of getting an STI are offered testing for STIs every 3 months.

Source guidance

British Association of Sexual Health and HIV (2016) United Kingdom national guideline on the sexual health care of men who have sex with men, recommendations on STI and HIV testing.

Definitions of terms used in this quality statement

Men who have sex with men and are at increased risk of sexually transmitted infections
Men who have sex with men, who have:
  • condomless anal intercourse with partner(s) of unknown or serodiscordant HIV status over last 12 months
  • over 10 sexual partners, over last 12 months
  • drug use (such as methamphetamine, mephedrone, inhaled nitrites, gamma-butyrolactone (GBL), ketamine, and other novel psychoactive substances) during sex over last six months
  • multiple or anonymous partners since last tested
  • any condomless sexual contact (oral, genital or anal) with a new partner since last tested.
[Adapted from the British Association of Sexual Health and HIV guideline on United Kingdom national guideline on the sexual health care of men who have sex with men, recommendations on STI and HIV testing]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Who should take action?

Managers and staff, including receptionists and administrators, working in services that provide contraception and contraceptive advice to young people. This includes education, maternity services, pharmacies and voluntary and private sector organisations.
Managers and staff in children's services, social care organisations and young people's advisory and support services. This includes guardians, chaperones, interpreters and advocates.

What action should they take?

Ensure staff are trained to understand the duty of confidentiality and adhere to the recommendations and standards laid out in their organisation's confidentiality policy.
Ensure staff are familiar with best practice guidance on how to give young people aged under 16 years contraceptive advice and supportDepartment of Health (2004) 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. London: Department of Health . Ensure they are also familiar with local and national guidance on working with vulnerable young people.
Ensure those providing contraceptive services can assess the competence of young people aged under 16 to consent to receiving contraceptive advice and any treatment that may involve. They should also be able to assess the competence of other young people who may be vulnerable, for example, those with learning disabilities. Staff need to be able to gauge the young person's ability to understand the information provided, to weigh up the risks and benefits, and to voluntarily express their own wishes. Staff should also encourage young people to involve a parent or person with parental responsibility in the decision-making, where possible.
Ensure young people understand that their personal information and the reason why they are using the service will be confidential. Even if it is decided that a young person is not mature enough to consent to contraceptive advice and treatment, the discussion should remain confidential.
Reassure young people that they will not be discussed with others without their explicit consent. Explain that sharing information with another professional may be necessary if there are concerns, for example to protect a young person from possible harm or abuse. If this is the case, the young person should be told who needs to be informed and why.
Ensure the organisation's confidentiality and complaints policy is prominently displayed in waiting and reception areas, and is in a format that is appropriate for all young people.
Ensure young people are asked in private whether they wish anyone else to be present at their consultation.
Ensure staff are adequately supported and supervised. This includes establishing a formal debriefing process to help maintain client confidentiality and respect.
Socially disadvantaged young people may include those who are:
  • living in a deprived area
  • from a minority ethnic group (including gypsy and traveller communities)
  • refugees, asylum seekers and people recently arrived in the UK
  • teenage parents or the children of teenage parents
  • looked after or leaving care
  • excluded from school or do not attend regularly or have poor educational attainment
  • unemployed or not in education or training
  • homeless
  • living with mental health problems
  • living with physical or learning disabilities
  • living with HIV or AIDS
  • substance misusers (including alcohol misusers)
  • criminal offenders.

Glossary

commissioning for quality and innovation
Faculty of Sexual and Reproductive Healthcare
(also referred to as lasting and reliable contraception or LARC)
personal, social, health and economic
sexually transmitted infections
sexually transmitted infection

Paths in this pathway

Pathway created: March 2014 Last updated: March 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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