On the partner website levitra online pharmacy given a complete description how to take these tablets. Be sure to check before use.

Je l'ai acheté le médicament cialis prix deux ou trois fois, l'effet est des pilules superbes, je ne ne nous a pas déçus même si je suis au dernier étage sur la pilule. Männer werden empfohlen, für mindestens 30 Minuten für den angeblichen Geschlechtsverkehr durchschnittliche Rendite von cialis 20mg zu verwenden.

Committeedocs.northumberland.gov.uk


Sexual Health in Northumberland:
A Summary Needs Assessment
Version 2 February 2015 Authored by: Karen Herne, Public Health Service Manager Sophie Baird, Public Health Analyst CONTENTS
EXECUTIVE SUMMARY
This Sexual Health Needs Assessment (SHNA) has been prepared for the Northumberland Health and Wellbeing Board to inform them of the current position of sexual health, key sexual health needs and current service provision. Future recommendations to be considered by the Board will be based on national and local evidence. The commissioning of sexual health services is a complex issue. Commissioners, providers and wider stakeholders are collectively responsible through commitment and collaboration to maintain and improve integrated services that meet the needs and preferences of users that ensure sexual health, reproductive health and health protection is maximised. [1] It is important to include all of these factors when considering commissioning of sexual health services as they all link and support each other in meeting projected multiple outcomes. The rationale for this Sexual Health Needs Assessment (SHNA) is:  To understand the current needs for sexual health services for Northumberland residents  Facilitate improved sexual health outcomes and reduce inequalities in sexual health for Northumberland residents through making recommendations for future collaborative commissioning of cost effective sexual health services. The Framework for Sexual Health [2] acknowledges the relationship between sexual ill health, poverty and social exclusion, as well as the disproportionate burden of HIV infection on gay and bisexual men and some Black and Minority Ethnic (BME) groups. For Northumberland the main factors contributing to the high levels of sexual health need include deprivation and social inequality, with young people the group currently identified as most at risk of poorer sexual health. The strategic direction for sexual health provision should be based around access to testing and treatment for STIs and contraception, health protection and prevention education from an early age. When mapping some elements of sexual health in Northumberland, there appears to be a disproportionate disparity between the rural and urban areas in the county, with the South East coastal corridor carrying more of the burden of chlamydia, gonorrhoea infections and under 18 conceptions. This is probably a reflection that half of the county's population live in the 3% of urban land found in the South East of the county, and also this reflects the highest areas of deprivation in the county. Northumberland has higher rates of diagnosed STIs in the 15-19 year old population than the average rate for England, with higher rate in females of this age. Peaks in STI rates in males occur in those aged 20 to 24 years. The rate of newly diagnosed STIs in Northumberland in 2013 was 598 per 100,000 people. However, this figure is much higher in the 15 to 24 year old population, reaching 3,896 per 100,000 15-19 year olds, and 3,921 per 100,000 20-24 year olds. The most commonly diagnosed rates of STIs in Northumberland are as follows in order of most prevalent to least prevalent: 1. Chlamydia 2. Genital Warts 3. Genital Herpes 4. Gonorrhoea (GC) 5. Non Specific Genital Infection 6. Syphilis 7. HIV However it is worth noting that rates of prevalence vary in specific identified geographical or social groups. Northumberland has one of the lowest HIV prevalence rates in the country. It is important that HIV is diagnosed early to ensure effective treatment and to reduce onward transmission in the population. Between 2011 and 2013 in Northumberland one third of new HIV cases were late diagnoses. Teenage conceptions are at their lowest rates since the Teenage Pregnancy Strategy in initiated 1998, however this overall decline masks those of some of the most deprived wards of Blyth and Ashington where the rates are higher than the national average. The proportion of all conceptions in Northumberland that resulted in termination of pregnancy (TOP) in 2012 was 18%. This is similar to the previous two years. The proportion of under 16 conceptions leading to a termination of pregnancy is lower than the regional and national averages and 79% of terminations are performed within 10 weeks gestation. A key concern is that 23% of terminations in those under 25 years are repeat terminations and so further understanding is required to determine the reasons for this in order to address this problem. Sex and Relationships Education (SRE) is key role in equipping young people with knowledge and skills to be able to develop healthy sexual relationships with an accurate understanding on how healthy relationships are made, and through having the confidence to negotiate safe sex. SRE is delivered mainly through schools, either as part of the Personal, Social and Health Education (PSHE) curriculum, or as standalone SRE lessons. Although currently this is not a mandatory subject within education, it is strongly endorsed by the Secretary of State through guidance on Sex and Relationships [3]. Northumberland County Council offers support to all schools through the School Health Nursing service and the Health & Wellbeing and Specialist Health Improvement Team.
Table 1. Recommendations for considerations by Commissioners
Clinical
NHS England
County Council
Area Team
Explore effective ways of engaging service users and community groups in the delivery of sexual health services Ensure patient satisfaction surveys are undertaken by providers Ensure clear patient pathways to and from the ISHS to ensure safe and seamless patient journeys Ensure increased partnership working between key organisations, agencies and community groups with the ISHS Increase social marketing exercises in order to determine appropriate behaviour change interventions and accessible services in line with national campaigns Increase sexual health promotion outreach work, especially for vulnerable groups: BME groups, refugees and asylum seekers, looked after children, youth offenders, those with learning disabilities, sex workers, drug and alcohol users, etc. Engage local communities to act as champions and role models to encourage involvement in sexual health promotion and HIV testing Produce sexual health promotional material in partnership with local communities that are tailored to their needs using (where appropriate) nationally developed materials Consider the teenage pregnancy agenda and ensure that those at risk of under 18 conceptions are identified with early help and Support schools in their responsibility to provide high quality SRE and ensure provision of high quality SRE out of school in conjunction with the school nursing service, outreach services, youth service, looked after children and teenage pregnancy initiatives Run programmes to increase self-esteem, communication and negotiation skills targeted at young people at risk of poorer sexual health outcomes SRE at school and in the community should also raise awareness of sexual violence and rape. This should include partnership working with the local police Deliver collaborative, holistic and integrated harm reduction interventions that specifically target the most vulnerable communities Enhance cervical screening awareness, particularly across specific population groups and improve cervical screening pathways Ensure that pathways for sterilisation and vasectomy services Develop comprehensive and standardised data collection for all services and a memorandum of understanding to share relevant data Further innovative ways of improving access to LARC and EHC should be explored in order to maintain focus on reduction in unplanned conceptions Review the current delivery of all sexual health commissioned services to ensure cost-effective delivery, promote integration, quality, value for money and innovation in the further development of sexual health interventions and service An assessment of the training and education needs for local primary care teams in order to enable them to confidently undertake risk assessments and treatments should be considered as a mechanism for improving access to services Prevention efforts, such as increased STI testing and HIV testing should be sustained and continue to focus on groups at highest risk Ensure Equality Impact Assessments are regularly undertaken by all providers and reported upon Continue embedding chlamydia screening in primary care and sexual health services which emphasise regular repeat screenings as appropriate Continue focus towards achieving a chlamydia diagnosis rate of at least 2,300 per 100,000 15-24 year olds Explore the provision of GP enhanced care for HIV in primary Review patient pathways for psychosexual counselling Develop coherent HIV testing policy which increases the accessibility and availability of HIV testing in acute trusts, primary care and community outreach services that is targeted at specific risk groups Support women with unwanted pregnancies to make informed decisions about their options as early as possible Ensure STI (including HIV) testing as well as contraceptive services are provided by TOP services Develop Sexual Health Strategy and commissioning action plan 1. INTRODUCTION
A Health Needs Assessment (HNA) is a systematic method for reviewing the health issues facing a population (in this case from adolescence onwards), leading to agreed priorities and resource allocation that will improve health and reduce inequalities. A HNA is a recommended public health tool used to provide an opportunity to engage with specific populations and enable them to contribute to targeted service planning and provides an opportunity for cross-sectoral partnership working to developing creative and cost effective interventions. In this case a SHNA was initiated as a pragmatic desk based exercise which sets out recommendations for further strategic direction. The scope of this document excludes a Service Review but can be used as a tool to inform commissioners and providers about aligning priorities. What is Sexual Health? The World Health Organisation defines sexual health as a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion [4]. Sexual health affects physical and psychological wellbeing and can have an enduring impact on overall quality of life. It is a key part of our identity as human beings together with the fundamental human rights to privacy, a family life and living free from discrimination. The World Health Organisation [4] defines the core elements of good sexual health which include equitable relationships and sexual fulfilment with the ability of men and women to achieve sexual health well-being through:  Access to comprehensive good-quality information about sex and sexuality  Knowledge about the risks they face and their vulnerability to the adverse consequences of sexual activity  Access to sexual health care at a convenient time and place  An environment that affirms and promotes sexual health. Sexual health concerns are wide-ranging, encompassing sexual and gender identity, sexual expression, relationships, and pleasure. They also include negative consequences or conditions such as:  Sexually Transmitted Infections (STIs) including infections with human immunodeficiency virus (HIV), and their adverse outcomes (such as cancer and infertility)  Unintended pregnancy and termination of pregnancy  Sexual dysfunction  Sexual violence  Harmful practices (such as female genital mutilation, FGM) The importance of improving sexual health is acknowledged by the inclusion of three indicators in the Public Health Outcomes Framework (PHOF). These indicators have been prioritised, as each represents an important area of public health that requires sustained and focused effort in order to improve outcomes. The indicators are:  Under 18 conceptions  Chlamydia diagnosis (15-24yr olds)  People presenting with HIV at a late stage of infection The commissioning responsibilities of Local Government, Clinical Commissioning Groups (CCGs) and NHS England for Sexual Health and HIV services are set out in the Health and Social Care Act 2012, as detailed below. Table 2. Sexual Health Commissioning Responsibilities
Clinical Commissioning
Local authorities
NHS England
Comprehensive, open  Termination services  Contraception as access sexual health  Sterilisation provided as additional services including: service of GP contract Contraceptive services HIV treatment and care Non-sexual health STI testing and treatment (including post-exposure elements of psychosexual  Promotion of National Chlamydia  Gynaecology, including opportunistic testing and Screening Programme contraception for non- treatment for STIs and  Psychosexual counselling contraceptive purposes patient requested testing  Sexual health specialist services (including young  Sexual health elements people's services, of prison health services teenage pregnancy  Sexual Assault Referral services, outreach, prevention and promotion, services in educational  Cervical screening establishments and  Specialist foetal medicine The Department of Health has recently published a Framework for Sexual Health setting out the nation's ambition and objectives as shown below. [2] Figure 1. Framework for Sexual Health
Source: Department of Health
The scope of this document promotes discussion about the maintenance and development of sexual health including the provision of services for all forms of contraception, detection and treatment of infections that are transmitted sexually (where sexual intercourse is the most common mode of transmission). There are other infections and diseases that can be transmitted sexually but are not covered in this report e.g. Hepatitis B and C. Many people with STIs, which include HIV, are unaware that they have a disease and may remain undiagnosed for many years. This not only affects their overall health and wellbeing but increases the risk of onward transmission in the population. Unplanned pregnancies, terminations and teenage conceptions can lead to many long term emotional, health and social consequences. Sexual dysfunction can affect self-esteem leading to relationship problems. Sexual behaviour is a major determinant of sexual and reproductive health. Certain behaviours are associated with increased transmission of Sexually Transmitted Infections (STIs) and HIV, including:  age at first sexual intercourse  number of lifetime partners  payment for sexual services  alcohol and/or substance misuse Therefore, ensuring access to appropriate sexual health information, interventions and services can have a positive effect on population health and wellbeing as well as individuals at risk. 2. WHO IS AT RISK AND WHY?
There has been a change in the sexual health behaviour of the population of England in the last 60 years. Recent evidence in the National Survey of Sexual Attitudes and Lifestyles (Natsal) which has been undertaken in 1991, 2001 and 2011, thus provides trend data [5]. The Natsal survey demonstrates:  an increase in the number of sexual partners over a person's lifetime, particularly for women where this has increased from 3.7 (1991) to 7.7 (2011)  an expansion of the sexual repertoire between heterosexual partners, particularly with oral and anal sexual intercourse All sexually active individuals of all ages are at risk of STIs (including HIV) and unplanned pregnancies (in the fertile years). However, the risks are not equally distributed amongst the population with certain groups being at greater risk. Poor sexual health may also be associated with other poor health outcomes. Those at highest risk of poor sexual health are often from specific population groups with varying needs which include:  Young people  Some black and ethnic minority groups  Men who have sex with men (MSM)  Sex workers  Victims of sexual and domestic violence  Other marginalised or vulnerable groups including prisoners It is important to recognise that MSM can be and are a marginalised and hard to reach group as they come from all backgrounds. It is also important to note that not all MSM will identify as being gay or bisexual and they can present themselves as heterosexual to the wider population and healthcare services. Therefore, there is no one particular characteristic which identifies the MSM population, as they are not a homogenous group. The reasons for this are diverse but set in a backdrop that societal attitudes to homosexuality remain markedly less liberal than attitudes to premarital sex. There is also a clear correlation between the acquisition of STIs and deprivation. There could be multiple reasons for this including:  inadequate service provision  lack of skills, knowledge and confidence about practicing safer sex  differences in healthcare seeking behaviour The type of sexual activity that people engage in can also increase the chances of contracting a STI, HIV infection or having an unplanned pregnancy, for example:  having multiple sexual partners  any sex without barrier protection  inappropriate contraceptive methods In the case of unplanned pregnancies, women at greater risk are:  those who do not use any form of appropriate contraception  young women who are unaware of their increased fertility or ‘test' their fertility  older women who are unaware of their continuing fertility  those with low educational attainment or aspirations 3. THE LEVEL OF NEED IN THE POPULATION
SEXUALLY TRANSMITTED INFECTIONS (STIS)
In 2013 Northumberland ranked 188 out of 326 local authorities in England for rates of new STIs1 (the first in the rank had the highest rate). 1,855 new STIs were diagnosed in Northumberland residents, a rate of 586.8 per 100,000 residents (compared to 810.9 per 100,000 in England). As shown in Figure 2, this rate is one of the lowest in the North East.
Figure 2. Rates of acute STIs in each local authority in the North East Public Health England
Centre: 2013
Source: Public Health England, LASER 2013
The rate of new STIs varies greatly within Northumberland with the most deprived quintile having a rate of 743 per 100,000 people. This is a huge leap from the rate of 405 per 100,000 in the next most deprived quintile. Areas that fall into the most deprived quintile are generally located in South East Northumberland. 1 The group of infections conventionally considered as acute STIs are: chlamydia; gential warts; gonorrhoea; syphilis; herpes; HIV/AIDS Figure 3. Rates of new STIs per 100,000 people by deprivation category within
Northumberland (Genito Urinary Medicine diagnoses only): 2013
Source: Public Health England, LASER 2013
Figure 4. Map of the distribution of the Index of Multiple Deprivation 2010 in
Northumberland, by lower super output area
Source: Northumberland Knowledge
Chlamydia
Chlamydia is the most common bacterial STI in both England and Northumberland where the prevalence is highest in the young adult population aged 15-24 years (Figure 5). Chlamydia infection is often asymptomatic so can therefore go undiagnosed for months and even years, leading to complications such as pelvic inflammatory disease (PID). In fact, PID is the only sexual and reproductive health indicator for which Northumberland performs poorly with a rate of 277 per 100,000 women aged 15 to 44. This is higher than the national and regional averages of 228 and 216 per 100,000 respectively.
Figure 5. Total chlamydia diagnosis rates per 100,000 men and women in Northumberland
(2013) – ALL AGES
Data source: GUMCAD (NB. These data include CSP data)
elpoep 3000
100, rep 1000
Age (years)
Chlamydia testing is provided through a variety of systematic programmes with potential for them to be aligned. These main approaches to testing for Chlamydia include the National Chlamydia Screening Programme (NCSP) which is a dedicated programme for testing young people within the population aged 15-24 years, and for those outside of the NCSP range, Chlamydia is tested for as part of the core Genito Urinary Medicine (GUM) services or through Primary Care settings. The NCSP is delivered in a variety of settings in Northumberland including Community Sexual Health Services, GP practices, pharmacies, youth centres, schools and Further Education colleges. Data on Chlamydia is also collected in two ways nationally by Public Health England. The GUM clinics and Primary Care collect data through a national system called Genito Urinary Medicine Clinic Activity Data (GUMCAD) and the NCMP collects data through their monitoring system. Public Health England reports the cleansed data from both sources and publishes on an annual basis via the Chlamydia Activity Dataset (CTAD). The diagnosis rate for Chlamydia has been included as an indicator in the Public Health Outcomes Framework with the current national aim being 2,300 per 100,000 of the 15-24 year old population, set by Public Health England in 2013. In 2013/14 Northumberland's total Chlamydia diagnosis rate (which affects the 15-24 year population only) fell just short at 2,295 per 100,000 which was higher than the national rate of 1,979.1 per 100,000. NCSP recommend that amongst those tested, the percentage infected/positivity rate should be maintained in the range of 5% to 12%. However, Northumberland's positivity rate is lower than this at 4.6% so as intelligence tells us that Chlamydia is the highest STI in the county, the lower positivity rate suggests chlamydia testing is not currently being effectively targeted. In the past the emphasis has been on testing high numbers of younger people through specific mass group events in Year 11, 12 & 13 at secondary schools. On further analysis, positivity rates are within the recommended range for those aged 20 to 24 years, but below for those aged 15 to 19 years. Positivity should therefore be reviewed by venue type in this age group to determine whether it is necessary to target differently. Figure 6. Chlamydia positivity rates in Northumberland, by age and gender (2013/14)
Data source: Newcastle upon Tyne Hospitals
Recommended range Age (years)
Chlamydia diagnosis rates in GUM clinics have increased in recent years, particularly in females. In fact, female diagnoses have been at the same rate as the England average (390 per 100,000), while rates in males have remained below 300 per 100,000. Figure 7. Trend of chlamydia diagnosis rates in GUM clinics per 100,000 people of all ages
(2009-2013)
Data source: GUMCAD
Northumberland males Northumberland females elpoep 300
100, rep 100
More women are diagnosed with chlamydia than men and the highest chlamydia diagnoses occur around Blyth, Ashington, Morpeth and Ponteland (Figures 6, 7 and 8). Figure 8. Map of chlamydia diagnosis rates in GUM clinics per 100,000 15-24 year olds
within Northumberland, by MSOA and CCG locality (2011-2013)
Data source: Public Health England
Figure 9. Map of chlamydia diagnosis rates in GUM clinics per 100,000 15-24 year olds
within South East Northumberland (2011-2013)
Data source: Public Health England
One reason why higher rates of positivity are found in GUM clinics could be due to the fact that people attending GUM are more likely doing so because they have symptoms of infection or are from a higher risk group therefore more likely to have disease. There needs to be a continuation of the focus on embedding chlamydia testing in primary care, sexual health services, and other community venues such as local pharmacies, emphasising the need for repeat testing as appropriate. Human Papilloma Virus (HPV)
There are more than forty types of the HPV which can be transmitted sexually. Certain HPV infections can cause cancers (e.g. cervical) and genital warts. In the UK, since 2008 all 12-13 year old girls are offered HPV vaccination through a national HPV immunisation programme which confers protection against cervical cancer and genital warts, in the hope to reduce the incidence of cervical cancer rates. Genital warts
Genital warts in Northumberland reflect the national trend as being the second most common STI in England, with diagnoses increasing steadily over the last decade. Whilst genital warts themselves are benign, certain strains of the virus can have serious impact on cervical tissue (see above). The virus is also often difficult to eradicate so whilst many STIs are treated through one or two clinic visits, a client with genital warts often requires multiple treatment sessions. Genital warts are the second most common STI in Northumberland with 117 diagnoses made per 100,000 people in 2013. Although the rate of this viral infection has been steadily decreasing in Northumberland women in recent years, rates are higher in men and these rose to 141 per 100,000 men in 2011. These rates do seem to have settled in Northumberland now and in 2013 diagnosis rates were maintained at 128 per 100,000 men. 107 diagnoses were made per 100,000 women.
Figure 10.
Trend of genital warts diagnosis rates per 100,000 people (2009-2013)
Data source: GUMCAD
Northumberland males Northumberland females The highest rates of genital warts occur in the Blyth Valley CCG locality, Ashington and Newbiggin. However there are also high rates around Alnwick and Hexham. (Figures 11 and 12). Figure 11. Map of total genital warts diagnosis rates per 100,000 people within
Northumberland, by MSOA and CCG locality (2011-2013)
Data source: GUMCAD
Figure 12. Map of total genital warts diagnosis rates per 100,000 people within South East
Northumberland, by MSOA (2011-2013)
Data source: GUMCAD
Gonorrhoea
Nationally, the rates of gonococcal (GC) infection had been reducing between 2005 and 2009. However, since 2009 there has been a noticeable increase in trend, particularly in 2012. This trend began in the summer of 2011 where an outbreak of GC infection was noted. An Enhanced Gonorrhoea Surveillance Study (EGS) was initiated in 2011 and concluded in Dec 2014 to help better understand who was being affected, how transmission was occurring and how best to target prevention and control of the outbreak. There are a number of issues about the rise in gonorrhoea 1. There have been changes in testing, moving to use more sensitive testing which will have detected more cases. However, had that been the only issue we would have expected rates to plateau once the testing had changed but in this case numbers have continued to increase, showing that there is continuing increase in cases 2. The current outbreak in the SE Northumberland area, that has been going on since summer of 2011, has been affecting a new population – young heterosexual adults (compared to ‘usual' cases who were MSM From the data collected during the EGS the group most affected in the outbreak were identified as female, heterosexual and under 30 years of age. This contrasts to the national picture where the highest risk group for GC is homosexual males, as cited above. Introducing dual testing for GC alongside Chlamydia was part of the outbreak control team's strategy to identify cases early so they could be treated and partners identified.
Figure 13. Trend of gonorrhoea diagnosis rates per 100,000 people (2009-2013)
Data source: GUMCAD

Figure 14.
Gonorrhoea diagnosis rates in Northumberland per 100,000 people, by gender
and age (2013)
Data source: GUMCAD
o
e
p
500
000 400
100, r 300
Age (years)
It is also important to note that the positivity rate in females aged under 15 years is 5%. Figure 16. Gonorrhoea positivity rates in Northumberland, by age and gender (2013/14)
Data source: Newcastle upon Tyne Hospitals
Age (years)
It should be noted that gonorrhoea is becoming more difficult to treat as there are increasing levels of antibiotic resistance, which mean that it is important that people are referred to appropriate services where they are managed correctly (and not prescribed ineffective antibiotics which will worsen the problem of resistance). This has implications for future complex treatment options and why there is a need for stronger focus on prevention and protection and a need for creative follow up of the partners of patients who are resistant to accepting treatment. Also worth noting is that partner tracing has been challenging with only 67% of those identified in the North East successfully treated. Within Northumberland gonorrhoea is concentrated in the Blyth Valley locality with very small numbers of diagnoses scattered across the rest of the outbreak area (Figure 17). Much as with chlamydia, most cases of gonorrhoea occur around Blyth, Ashington and Morpeth. Figure 17. Map of gonorrhoea diagnosis rates per 100,000 people in South East
Northumberland (2011-2013)
Data source: Public Health England
Syphilis
Syphilis is one of the least common STIs in the country with low rates reported locally and nationally. There has been a recent increase in diagnosis in the North East (mainly in the inner city areas) resulting in an enhanced surveillance programme, however when Northumberland is compared against peer comparators there are lower reported rates. In Northumberland 29 diagnoses were made between 2010 and 2012. This equates to an overall rate of 3 diagnoses per 100,000 people. In 2013 only 0.6 diagnoses were made per 100,000 people and this is significantly lower than the national and regional averages (6 and 5 per 100,000 respectively).
Figure 18. Trend of syphilis diagnosis rates per 100,000 people (2009-2013)
Data source: GUMCAD
Northumberland males Northumberland females 100, re 2p
Genital Herpes
Genital herpes is a viral infection that requires anti-viral therapy and it often requires long term management through suppressive anti-viral therapy. Since 2010, diagnoses of genital herpes have been increasing in both men and women and now stand at 33 and 61 per 100,000 men and women respectively (Figure 19). Figure 19. Trend of genital herpes diagnosis rates per 100,000 people
Data source: GUMCAD
Northumberland males Northumberland females o
e
p
40
000 30
100, r 20
Rates of genital herpes in Northumberland are highest in females aged 15 to 19 years (367 per 100,000) and 20 to 24 years (354 per 100,000).
Figure 20. Diagnosis rates of genital herpes in Northumberland, by gender and age (2013)
Data source: GUMCAD
100 re 100
Age (years)
Human Immunodeficiency Virus (HIV)
HIV is a serious health condition in the UK. Although there have been significant improvements in survival for people with HIV over the past two decades, HIV infection can still be associated with higher risks of serious physical and mental ill health, reduced life expectancy (if treatment not started early), discrimination and poverty. Early diagnosis is important in order for anti-retroviral treatment to be provided and for further transmission in the population to be reduced. Public Health England (PHE) estimates that 100,000 people in the UK were living with HIV in 2012, with nearly one in four being undiagnosed and unaware of their infection. It is also reported that UK-acquired infections in MSM and in heterosexuals continue to rise while infections acquired from abroad continue to decline. The two groups most affected by HIV in the UK are MSM and people who have migrated from regions of the world where HIV is common, such as sub-Saharan Africa. Nationally, there has been a 27% increase of HIV infections acquired within the UK from 2002-2011. In 2011, almost four out of five newly diagnosed MSM probably acquired HIV in the UK. 48% of people diagnosed with HIV in the UK (2011) had been infected heterosexually with 57% of those being black African. Key recommendations are as follows:  increasing the number of HIV tests in non-specialist healthcare in areas with a high prevalence of HIV [6]. Findings from pilot projects indicate that offering HIV tests outside sexual health clinics is feasible and acceptable to patients as well as staff [7].  increasing the uptake of HIV testing among black Africans in England [8] and MSM [9]. A recent review also suggests that rapid testing in community settings and intensive peer counselling (where appropriate) can increase the uptake of HIV testing among gay and bisexual men [10]. In Northumberland 51% of HIV diagnoses were contracted through sex between men. In addition, 37% of diagnoses were through heterosexual contact. Areas with a diagnosed HIV rate of more than 2.0 per 1,000 population aged 15-59 years are defined as areas of high prevalence. In Northumberland in 2013 this rate stood at 0.45 per 100,000 with 95 Northumberland residents accessing HIV-related care. Two thirds of those with a HIV diagnosis in Northumberland were receiving anti-retroviral therapy in 2013. There are other modes of transmission including mother to child transmission, blood products and intravenous drug use. All of these are now either rare or in very low numbers due to a variety of successful public health interventions including antenatal testing, blood testing and needle exchange schemes. LATE DIAGNOSIS
Late diagnosis is one of the biggest contributing factors to illness and death for people with HIV. The PHE National Annual Report in 2013 cited that 47% of people with HIV who were diagnosed late had a ten-fold increased risk of death in the first year of diagnosis compared to those diagnosed with earlier infection. [1] The Public Health Outcomes Framework includes an indicator for the reduction in the number of people presenting with HIV at a late stage of infection. A person is considered to have been diagnosed late if the number of particular immune cells (CD4 cells) in their bloodstream has dropped below a certain level. Between 2011 and 2013, the HIV late diagnoses rate in Northumberland (30%) compares well against the England average of 45%. However it is important to note that this figure is very small (3 of the 10 new HIV diagnoses in Northumberland between 2011 and 2013 were diagnosed late). Nationally, HIV testing coverage among attendees of genitourinary medicine (GUM), antenatal services, needle exchange and other drug services is high. HIV testing coverage in Northumberland ISHS clinics is generally very high with 83% of women, 85% of men and 96% of MSM accepting HIV tests when offered. PROPHYLAXIS TREATMENT
Post exposure prophylaxis (PEP) is a drug treatment schedule that can be offered to an individual who has been at risk of being infected by HIV, either through sexual intercourse (PEPSE) or needle exposure (PEP). Both PEP and PEPSE can be accessed within 48 hours of exposure at the ISHS or the local Accident and Emergency department. At this point it is unclear regarding the uptake of these. The scope of information on contraception in this Needs Assessment is limited due to lack of data from specific partner agencies. Data excludes generic contraception provided in out-patient clinics or as part of secondary care pathways such as from the termination of pregnancy service, as we are unable to access such information. Contraception Choices
Long Acting Reversible Contraception (LARC) has altered the way proactive contraception is promoted. LARC is cited by the National Institute for Health and Care Excellence (NICE) as being the most reliable form of contraception and is recommended for preventing teenage pregnancy and reducing the demand upon termination services by women of all ages. NICE guidance recommends increased provision of LARC as they are well tolerated by women and cost-effective with a saving to the NHS of £13 for every £1 spent on LARCs. There are various methods available including:  Intrauterine Contraceptive Methods (IUCs) which include Devices (IUD) and Systems (IUS) and are also called coils  Subdermal Implants (SDI) also called implants  Depo-Provera injections However, in addition to LARC methods there remains strong alternative provision of oral hormonal contraception and a reliance on barrier methods. Best practice would recommend a couple should use a reliable contraceptive method alongside barrier methods for STIs (condoms) for couples in new or short term relationships. Primary Care
Primary Care continues to be the main source of provision for contraceptive methods throughout Northumberland. The vast majority of GPs provide generic oral contraception and injectable LARC methods which is commissioned by NHS England. This Primary Care provision is very important given the geographical landscape of the county and endorsed by an online survey of the general public carried out in May 2014 (more detail on this in Section 7). By far the two most prescribed contraceptive products in Primary Care are the Combined Oral Contraceptive pill and the Progestogen Only Pill [Data source: North East Commissioning Support Unit, 2014]. The GP prescribed LARC rate in Northumberland is one of the highest in England at 80.6 per 1,000 women. Prescription data show that 11,420 units of LARC methods were prescribed in primary care in 2013/14. Of these, 83% were contraceptive injections, 9% were Intra Uterine Contraceptive (IUC)s, and 8% were SDIs. Contraceptive injections are not commissioned by the LA Public Health and are funded through NHS England as part of core contraceptive funding.

Figure 21.
Rate of enhanced LARC insertions (IUC and SDI only) in GP surgeries
commissioned by Public Health Northumberland, by age group
Data source: 2013/14 contract data
100, re p 1500
However the LA does pay for non-injectable LARC methods through an enhanced funding arrangement with Primary Care providers. These include copper coils (for contraception and emergency contraception), intrauterine systems (for contraceptive purposes only) and subdermal implants. The rates of LARC insertions in Public Health commissioned GP practices in 2013/14 were highest in those aged 19 to 25 years (3,399 per 100,000), followed by those aged 26 to 35 years (3,169 per 100,000) and 17 to 18 years (3,160 per 100,000). Figure 22. LARCs insertions at GP surgeries in Northumberland, by contraceptive method
and age
Data source: 2013/14 contract data
Age (years)
In GP surgeries commissioned by Public Health, the highest rates of LARC insertions in Northumberland take place in the Central and West CCG localities (Figure 23 below). Figure 23. Rate of LARC insertions in GP surgeries commissioned by Public Health
Northumberland, by LSOA and CCG locality
Data source: 2013/14 contract data
Community Contraception provided by Integrated Sexual Health Service (ISHS)
In 2013/14 there were 9,971 client contacts for contraceptive support in the ISHS, of which 51% were new users of the service. Of these contacts, 44% were provided with a Long Acting Reversible Contraceptive (LARC) method and 55% were provided with a user dependent method, such as oral contraceptives [HSCIC, 2014]. Contraception and Sexual Health (CASH) services are located within community and hospital venues throughout the county with most of the Secondary Schools in the county allowing access to a weekly session on site. Emergency Contraception
Emergency contraception can be used to prevent pregnancy after unprotected sexual intercourse or if a method of contraception has failed. There are two methods of emergency contraception:  the copper intrauterine device (IUD)  the emergency hormonal contraceptive pill COPPER INTRAUTERINE DEVICE (IUD)
The IUD can be fitted by an appropriately trained clinician within five days of unprotected sexual intercourse or up to five days after ovulation. It is the most effective method of emergency contraception and prevents at least 99.9% of pregnancies. All women should be offered an Emergency IUD and pharmacists have a pathway for referral to local ISHS services or GPs who are able to provide such a procedure. There is a requirement for improved data monitoring of uptake of these pathways. EMERGENCY HORMONAL ORAL CONTRACEPTION (EHOC)
There are two types of emergency contraceptive pill offered and provided dependent on the patient's suitability:  Type 1 - which can be taken up to three days (72 hours) after unprotected sexual intercourse and is available free of charge on prescription or can be bought over the counter.  Type 2 - which can be taken up to five days (120 hours) after unprotected sexual intercourse, however is only available on prescription. Both methods are currently provided as part of a free scheme, 7 days a week by 74 local pharmacies across Northumberland. The community pharmacy scheme saw 1,970 women in 2013/14 who qualified for EHOC.

Figure 24.
EHOC requests by age in each CCG locality
Data source: Public Health contract data (2013/14)
CONDOM AND PREGNANCY TESTING PROVISION
Free condoms are available across Northumberland to all young people under the age of 25. The scheme is called the ‘C.Card Scheme' and is available in 86 venues including schools and Further Education colleges, GP's, pharmacies, ISHS, youth and community settings. Trained workers provide condoms along with instructions on their use, safe sex health promotion including negotiation and decision support for delaying first sexual intercourse. 29% of women who went to a pharmacy for EHOC were supplied with a condom pack in 2013/14. Of these, 8% were supplied in conjunction with a C.Card.
Figure 25.
Proportion of women who sought emergency contraception at a pharmacy who
were supplied with a condom pack, by age (2013/14)
Data source: Contract data 2013/14
Yes - with C.card Free pregnancy testing is available at the ISHS, GPs and local pharmacies. The school health nursing team will in future also be able to offer pregnancy testing following training to ensure robust pathways are available to manage unplanned positive tests. TEENAGE PREGNANCY
Teenage pregnancy is a significant public health issue as it is widely recognised that an unplanned teenage conception is a predetermined factor in poorer health outcomes for both the mother and child. As one of the proxy indicators for poorer health, teenage pregnancy is often linked to deprivation rates and higher STIs. The National rate of live births in 15-19 year olds remains higher than the European Union (EU) average for 2012 at 19.7 per 1,000. Only Romania and Bulgaria are higher in Europe and other high income countries outside the EU with higher rates include Australia, New Zealand and the USA. The most successful EU countries are Denmark, Slovenia, Netherlands and Sweden with evidence that societal attitudes and strong emphasis on sexual health education and prevention being a key factor of their success.
Table 3. International live birth rates per 1,000 women in each age group (2012)
Data source: Office for National Statistics
Aged 15-19
Aged 15-17
There is increasing evidence that unplanned teenage pregnancies have poorer pregnancy outcomes, with children that are born tending to have a more limited vocabulary with poorer non-verbal and spatial abilities. These differences are compounded by deprivation and inequalities [11]. Although teenage conception may result for a variety of reasons, the strongest empirical evidence for prevention are:  high-quality education about sex and relationships (SRE) [12]  access to and correct use of effective contraception [13] A partnership strategy has been implemented in Northumberland over the last 10 years to support the reduction in under 18 conceptions. This has included an increased effort in improving education in schools along with information on access to contraception and sexual health services. At the time of reporting data for 2012 revealed the teenage pregnancy rate nationally reached its lowest rate since records began, with Northumberland slightly higher than the national average (28.4 per 1,000 compared to 27.7). NOTE: Updated data for 2013 demonstrates Northumberland under 18 conception rates have fallen significantly and are now below the national rate at 22.9 per 1000 compared to the national rate of 24.3 – this demonstrates a fall of 49% since the teenage pregnancy strategy began in 1998 where rates were 41.8 per 1000 conceptions. Figure 26
Figure 27. Map showing under 18 conception rates within Northumberland by ward, 2010-
2012
Data source: ONS Figure 28. Map showing under 18 conception rates within South East Northumberland by
ward, 2010-2012
Data source: ONS
TERMINATION OF PREGNANCY (TOP)
Termination of Pregnancy (TOP) is governed by the Abortion Act of 1967 which permits terminations up to the 24th week of gestation by regulated providers. In Northumberland these services have been commissioned predominately from Northumbria Healthcare Foundation Trust and, on a smaller scale, from Newcastle City Trust and British Pregnancy Advisory Service (BPAS) both based in Newcastle. Transport is a major issue especially for young people who have restricted independent means of travel and often rely on public transport. The rail network often means it is easier for a woman to travel into Newcastle to access a service. This is especially important when 2-3 visits are required and clinic times conflict with work or education requirements. TOP services are commissioned by the CCG in Northumberland therefore it is important that commissioning is aligned with local authority contraceptive commissioning priorities to ensure the best value for money. Therefore contraception (including LARC methods) should be provided where possible post termination in order to reduce the need for a repeated termination in the future. It is unclear as to uptake of post termination contraception. The total termination rate in Northumberland has decreased in recent years and now stands at 12.4 per 1,000 women aged 15-44.
Figure 29: Termination of pregnancy rate per 1,000 women aged 15-44 (2009-2013)
Data source: Department for Health
aged
n
e
10
The proportion of under 18 conceptions leading to termination is also lower than the national and regional averages, but not significantly so. Table 4 Trend of percentage of under 18 conceptions leading to termination
Data source: ONS Conceptions Statistics
North East
conception
Sterilisation services are commissioned by NHS Northumberland CCG and provided through the local NHS Foundation Trusts. However, it was not possible to obtain further detailed information of service provision at this time. VASECTOMY
Vasectomy services are commissioned by NHS Northumberland CCG and provided through the local NHS Foundation Trusts. However, it was not possible to obtain further detailed information of service provision at this time. PSYCHOSEXUAL COUNSELLING
The following data is from the ISHS Psychosexual Service. Services that address psychological and sexual problems are recommended as a vital part of modern comprehensive contraception and sexual health services under the Medical Foundation for HIV & Sexual Health (MEDFASH) National Recommended Standards for Sexual Health Services (2005). Access to, and provision of, psychosexual counselling is also recognised as imperative under the British Society for Sexual Medicine Guidelines (2008). The service is provided for individuals aged over 16 years and/or couples experiencing sexual difficulties such as erectile dysfunction, vaginismus, vulval pain issues, loss of drive, sexual addiction, and premature ejaculation. Psychosexual issues can be highly complex and multi-faceted and patients will frequently suffer sexual difficulty for many years before seeking help. Since its inception in 2004, the Sex Therapy service in Northumberland has seen the majority of referrals coming from GPs. Men account for 62% of referrals. In 2013/14 there were 325 appointments. On average clients require 6 sessions but this may vary depending on issue. CERVICAL SCREENING
As part of the national screening programme, cervical screening is offered to all women aged 25 to 64 years as follows:  every 3 years to those under the age of 50  every 5 years to those over 50 years The test, historically known as the ‘cervical smear' is designed to ascertain the health of the cervix which gives an assessment of the risk of developing cervical cancer. Testing for HPV (human papilloma virus) is also now part of the programme. The cervical screening programme is paid for by NHS England and facilitated through Primary Care, where the majority of cervical screening takes place, and the ISHS, Obstetrics and Gynaecology and private hospitals. Cervical screening rates have decreased slightly in Northumberland over the last three years but they are consistently higher than the national average, which is also decreasing. Table 5. Cervical screening rates as a proportion of the eligible population (women aged 25-
64), by locality and year
Data source: Patient Services, Area Team, NHS England Locality
SEXUAL VIOLENCE
Services for those affected by sexual violence are paid for by NHS England. The scope of this document excludes Child Sexual Exploitation and Female Genital Mutilation as these subjects are covered in other reports. The Sexual Assault Referral Centre (SARC) for Northumberland is currently jointly commissioned between NHS England and Northumbria Police. A Sexual Violence Needs Assessment was undertaken for Northumberland in April 2014, details of which can be found here: Data collected as part of the national Violence Indicator Profiles for England Resource (VIPER) indicate that the crude rate of recorded sexual offences for Northumberland in 2011/12 (0.65 per 1,000 population) was the fourth lowest in the North East (see Figure 31 below). The number of sexual offences recorded in Northumberland during this time was 204. Figure 30. Sexual offences, crude rate per 1,000 population (2011/12)
Data source: Violence Indicator Profiles for England Resource (VIPER)
Newcastle upon Tyne Redcar and Cleveland 4. EVIDENCE OF COST EFFECTIVENESS
There is evidence demonstrating that spending on sexual health interventions and services is cost effective:  The overall cost of sexual health promotion is minor compared to the costs of treating STIs and unintended pregnancies.[1]  Rapid access to confidential, open-access, integrated sexual health services in a range of settings that are accessible at convenient times, ensures early treatment of STIs and partner notification are cost-effective interventions [14]  Early, accurate and effective diagnosis and treatment of STIs (including HIV), combined with partner notification [15] (in order to manage and control STIs by protecting: patients from re-infection; partners from long-term consequences of untreated infection; and the wider community from onward transmission) [16]  Improvements in the rates of partner notification reduces the cost per chlamydia infection detected [17] Preventing HIV transmission in the first instance is cost effective:  HIV is responsible for a significant burden on NHS resources. Due to recent increases in drug costs and longer life expectancy, the average lifetime treatment costs for an individual who is HIV positive is currently estimated at around £360,777 based on predicted median age at death of 75yrs. [18]  Data from 1996 to 2008 showed that the annual estimated cost for starting standard first line anti-retroviral therapy was £12,812 for HIV positive individuals who were severely immunocompromised but 18% less (£10,478) if treatment was initiated sooner [19]  Early access to HIV treatment significantly reduces the risk of HIV transmission to an uninfected person with consequential cost savings [20] Preventing unplanned pregnancies is cost effective:  The provision of contraception saves the NHS £6.2 billion in healthcare costs that would otherwise have been spent if no contraception was provided [21].  Every £1 invested in LARC methods of contraception, saves £13 in averted  Cost savings can be realised if the utilisation of LARC methods is increased  LARC methods are much more effective at preventing pregnancy than other methods, although a condom should also always be used to protect against STIs [22] 5. CURRENT SERVICES AND ASSETS IN RELATION TO NEED
Due to the size of the county sexual health services are provided from a range of community and hospital based venues. The majority of sexual health services is provided to Northumberland residents by Northumbria Healthcare Foundation Trust (NHFT) and paid for by Northumberland County Council. The community of sexual health providers across Northumberland is supported by a network of clinically focused expertise. The community based ISHS is commissioned by the local authority. This includes:  Genito-Urinary Medicine (GUM) STI testing and treatment services  Contraceptive and Reproductive Health services (excluding sterilisation),  Chlamydia and Gonorrhoea testing programme  Specific Young People services  Psychosexual services  C.Card Scheme - a free condom scheme to under 25's This Integrated Sexual Health Service (ISHS) is provided through a hub and spoke model offering the majority of community venues in the South East, but also offers weekly sessions in the North and West of the county. The aim of the ISHS is to provide a range of accessible, high-quality, responsive, cost-effective, confidential services across Northumberland. The service supports and provides elements of delivery of sexual health services in primary care and other community settings through the provision of professional training. The service includes:  An open access Consultant-led ISHS with provision in appropriate locations across the county through a hub and spoke model of sexual health provision with the aim of meeting all the sexual health needs of an individual in one visit  Integration of STI management and contraceptive provision into one visit  Clinicians and nurses who are dual trained and able to meet the needs of the individual no matter what sexual health concern or condition they present with, minimising the need to see multiple practitioners  Multidisciplinary working that utilises the skills of clinicians and non -clinicians in a cost-effective and clinically appropriate manner  Flexible opening hours between 8:30am and 7pm on weekdays (Monday to Friday) and between 11am and 1pm on Saturdays  A young people's specific ISHS (for the under 25s)  Outreach and targeted work to higher risk groups through an integrated prevention and health promotion model  Provision of a domiciliary LARC service for residents who are unable to access local services  A specialist psychosexual counselling service for clients aged 16 and over  Training programme for Healthcare Professionals to enable wider delivery of LARC and contraceptive provision See Appendix 1 for current opening hours and venues of local community ISHS provision. The LA has a duty to pay for STI testing for Northumberland residents to any provider in the country ie Northumberland County Council must pay for STI testing for a Northumberland student living in Manchester. The majority of these out of area services are paid to Newcastle and North Tyneside service providers. The LA also pays for Chlamydia screening support and services for Men who have sex with Men (MSM) provided by Newcastle City NHS Trust. The Sexual Health in Northumberland (SHiN) group meets three times per year and includes commissioners, specialist clinicians, service providers, youth and health improvement specialists, GPs and community nurses with an interest in sexual health. GENERAL PRACTICE
General Practice provides the majority of contraceptive provision for registered patients via additional services of the General Medical Services (GMS) contract. GMS contracts are commissioned by the Area Teams of NHS England and include all forms of oral hormonal contraception and injectable LARC methods. This does not however include the provision of IUDs or Implants for contraceptive purposes. Although it is not a mandatory requirement for GPs to provide this additional element of the contract, most GPs in Northumberland have signed up to providing this service through an enhanced LARC contract paid for by the Local Authority. Healthcare professionals must meet specific training criteria in order to provide the service. PHARMACY
EHOC is currently available free of charge to those under the age of 25 in 41 community pharmacies in Northumberland. Only pharmacists who have undertaken training for the Patient Group Direction are allowed to participate in this scheme. Service provision may not always be consistent or available every day (as not all pharmacists in each pharmacy are trained). This scheme has proved very popular in Northumberland providing improved access across the county. TERMINATION OF PREGNANCY SERVICES
Northumberland Clinical Commissioning Group commission termination of pregnancy services from local NHS providers and a charitable not for profit Organisation. The aim of the service is to provide termination of pregnancies which are timely and safe depending on the personal health and circumstances of the individual service user, to reduce repeat terminations and unintended pregnancies and to promote better sexual health among service users. The objectives of the services are to provide a consistent, comprehensive, effective, accessible, legal and appropriate termination of pregnancy service to the residents of Northumberland. The services should comply with standards provided by the Royal College of Obstetricians and Gynaecologists Guideline for the ‘Care of Women Requesting Induced Abortion' (the RCOG Guideline), MEDFASH standards for sexual health services and current best evidence. The service is designed to ensure that opportunities for contraception information, supply and sexual health testing are maximised however we are unable to collect such data at this time. HIV TREATMENT AND CARE
Commissioned by NHS England (Area Team) and is primarily provided through secondary care by the specialised departments of Infectious Diseases and HIV at Newcastle City Trust, but more recently within Northumbria Trust community services. The delivery of HIV care and treatment is supported by a variety of skill-mix within the workforce and associated services including clinicians, psychologists and social workers. It is recommended to offer testing to those in the general population, those attending termination of pregnancy services, hospital general medical admissions, and primary care, as a feasible, acceptable, effective and cost-effective way to drive a reduction in late diagnosis (PHE, 2014). As part of a drive to reduce late HIV diagnosis Northumberland LA have agreed to take part in a national pilot study which is due to be implemented during the summer of 2015 on self-sampling for HIV, which will broaden the options available to people wishing to take a HIV test. Practice nurses and GPs have opportunities to discuss and assess risk of having or acquiring HIV with individual patients by promoting safer sexual practices and condom use with those who are or may be at risk. Opportunistic sexual health promotion interventions may occur during travel advice consultations, new patient checks, contraceptive care and cervical screening. [23] Further discussions are also being currently investigated regarding pre exposure prophylaxis for at risk clients SEXUAL ASSAULT AND RAPE CENTRES
Currently jointly commissioned by the NHS England Health and Justice Team and the police. The service is provided at a specialist centre in Newcastle, available 24 hours a day for those reporting sexual assaults/violence. The centres are safe locations where victims of sexual assault can receive medical care, counselling and a forensic examination quickly and sympathetically. Victims are offered emergency contraception, STI testing and referral to the GUM clinic for sexual health follow-up. There is a national exercise taking place with a consultancy (Pathway Analytics, due to report in March 15) to determine how SARC's will be funded in the future and although there will continue to be co-commissioning between health and police it is looking likely that CCG's will be part of the funding picture going forward, most likely for the on-going support/counselling for victims. PRISON SEXUAL HEALTH SERVICES
The Health and Justice team within NHS England lead on both the commissioning of prison healthcare (including SHS). It was not possible to obtain further detailed information of service provision. HEALTH PROMOTION AND SEX AND RELATIONSHIP EDUCATION (SRE)
There is considerable evidence that sexual health outcomes can be improved by accurate, high-quality and timely information that enables people to make informed decisions about relationships, sex and sexual health [12] Evidence suggests that preventative interventions that build personal resilience and self-esteem whilst promoting healthy choices [15], focus on behaviour change, and are based on behaviour-change theory have been effective in promoting sexual health [24] NICE has also suggested that helping people to work through their own motivations by encouraging them to question and change their behaviour can form a key part of preventative interventions in reducing STIs (including HIV) and reducing the rate of under 18 conceptions, especially among vulnerable and at risk groups [25]. Effective behaviour change interventions draw on a robust evidence base, are targeted at specific groups and take account of their specific influences and motivations to change and include provision of basic accurate information with clear messages. They should promote individual responsibility and focus on motivating the individual to change and make use of ‘changing contexts' models for ‘nudging' people into healthier choices while recognising that such choices are influenced by complicated drivers of human action, including gender roles, inequality and norms around sexuality [26]. SRE is important to ensure that both healthy and enjoyable sex lives are nurtured and developed. Sex education is currently not a prescribed a part of the curriculum in state schools, however there is guidance from the Secretary of State on what should be provided which follows the 21st Century Sex programme. Northumberland has a range of 3 tier and 2 tier education where there are differing levels of SRE provision in the 14 secondary schools. Some schools utilise school nurses in providing SRE and some buy in various national and local organisations to provide SRE support to teachers. The Local Authority pays for the school nursing team to offer SRE to all pupils in Years 5 and 8 attending state schools and academies across the county. The majority but not all of the schools take up this offer. In addition the Health and Wellbeing Team and Health Improvement Sexual Health specialists support teachers in delivering the sex education agenda. These partnerships work closely alongside the Sexual Health Specialists who provide one to one drop ins within 12 out of the 14 secondary schools. The Schools Sexual Health Strategic Partnership group co-ordinates training offers and delivery of services within schools. The LA purchases a Health Related Behaviour Questionnaire every 2 years, which seeks the views of young people in Year 8 and Year 10. This is a combination of actual health behaviour and perceived health behaviour of their peers. Part of this consultation includes sexual health issues and this tool has been used to direct some targeted work to date and will be used in future to ensure the issues important to young people are being addressed. Peer perception is very important for focusing health promotion trough social norms and sexual health lifestyle and influence an important aspect for trainers and those working with parents to acknowledge. HEALTHY LIVING PHARMACIES
A small number of healthy living pharmacies offer a range of sexual health promotion materials and supportive testing and referrals to the ISHS. LESBIAN, GAY, BISEXUAL AND TRANSGENDER SERVICES (LGBT)
Although there is open access to all community sexual health services, there are limited services targeted towards meeting the needs of the LGBT community in Northumberland. This includes a statutory organisation which is part of Newcastle City Council which predominantly caters for Men who have Sex with Men (MSM), and a Voluntary Community Service (VCS) who are based in Blyth, Northumberland. The Newcastle project is a community development model focused on HIV prevention and is currently commissioned on a small scale by the local authority. The core service provides a dedicated telephone advice line, website, drop in, one 2 one and group work for MSM (including HIV positive men), outreach work to the saunas and bars in Newcastle, and staff training for partnership agencies. The Blyth VCS is a charity that provides support and advice to the LGBT community aged under 25 years. They provide LGBT specific Sex Education, strategies for raising awareness of sexual exploitation within the context of LGBT community, forms of domestic abuse within intimate LGBT relationships, particularly early relationships. They also offer training & support for professionals on sexual exploitation of LGBT young people, and offer parent support & child-parent mediation and support of Transgender Young People through one to one and focused group work 1-2-1 work with LGBT young people. 6. PROJECTED SERVICE USE AND OUTCOMES IN THE NEXT 10
There is a clear relationship between sexual ill health, poverty and social exclusion. Parts of Northumberland experience either higher than national levels of deprivation or significant isolation (some experience both). There is also an increased need to ensure that SRE programmes and provision of Sexual Health Services within school settings address the greater vulnerability of adolescents to unprotected sex, sexual coercion (including grooming), STIs/HIV and unintended pregnancies, as these are also important factors in breaking the intergenerational cycle of poverty. The trends in Northumberland indicate increasing rates of STI's and whilst there has been a reduction in unplanned pregnancy the rates are slower than the national average. Therefore, addressing and reducing these trends are of significant importance. Sexual health and wellbeing as a subject is highly amenable to public health interventions. This includes high quality and age-appropriate SRE, universal accessibility to STI and contraceptive treatment and care services, and interventions targeted at specific groups with higher needs or risks. A late diagnosis of HIV infection tends to result in poorer outcomes, as treatment may not always be not as successful if presenting co-morbidities exist. This can then also lead to further or extra requirements for both health and social care support. As more people are living longer with HIV infection, there may also be a rise in the number of infected people seeking support and care as a long term condition. Secondary services need to consider the ageing HIV population who develop new co-morbidities as well as newly diagnosed patients. And, as the number of people affected by HIV infection increases, there will be further expectations of provision as partners, families and carers also require support. A further consideration worth noting in Northumberland is the ageing population structure and subsequent sexual health requirements. 44% of the population is currently aged 50 years or over, compared with 36% in the UK and 38% in the North East [Data source: ONS mid-2013 population estimates]. The age pyramid below clearly demonstrates the difference in population structure between Northumberland and England. Population projections estimate that half of the Northumberland population will be over 50 years old by 2033 (see Figure 32). In addition, the proportion of those aged under 35 years will decrease from 37% in 2013 to 33% in 2033.
Figure 31.
Population structure in Northumberland compared to that in England, 2013
Data source: ONS mid-2013 population estimates
7. UNMET NEEDS AND MISSING DATA
There is a need to make improvements in the following areas of sexual health services VULNERABLE GROUPS
Knowledge gaps in intelligence exist about key vulnerable groups which suggests there needs to be further specific quantitative and qualitative sexual health needs assessment on:  People of all ages with Learning Difficulties  Sex workers in Northumberland  Men who have Sex with Men  Men who have Sex with Men then return to heterosexual relationships  Mature people navigating new sexual relationships The World Health Organisation regularly publishes a european magazine for sexual and reproductive health, Entre Nous which has highlighted the fact that in recent years there has been increasing evidence globally that STI and HIV rates are growing in those aged 50 years and over. However, this is not reflected in sexual health promotion, care or treatment, possibly due to "a common perception of sexual inactivity in older age". [27] In reality, the rate of new STI diagnoses in people aged 45 and over in Northumberland in 2013 was 53 per 100,000, compared to 124 per 100,000 nationally so although this is a small rate in relation to young people, this is worth considering for future planning of social marketing campaigns and service access. A clearer understanding is needed of the services offered for HIV testing in Primary Care, the Voluntary sector and hospital based settings. It is perceived that the offer as well as the uptake of testing for HIV could be better, so urgent action is required to address this issue. There are currently gaps in our data with regard to pathways for HIV support and care and the number of post-exposure prophylaxis required and delivered. CHLAMYDIA SCREENING
Northumberland services are working towards achieving the chlamydia diagnosis rate of 2,300 per 100,000 (Public Health Outcomes Framework indicator). This target was not met in the 2013/14 period. It is understood that participation in the scheme from pharmacists and Primary Care is low and that the current local agreement remunerates coverage rather than targeting resources at specific young people at the greatest risk of having a positive result. The service specification is currently being reviewed. LONG ACTING REVERSIBLE CONTRACEPTION
Whilst the offer and provision of Contraceptive implants and coils are good throughout Northumberland, they are only cost effective when maintained for a minimum of 12 months, so there needs to be an audit of how well these methods are tolerated and maintained. The costs of LARC devices are substantial however good value for money when maintained, ideally for the lifetime of the device (a minimum of 3 years). The unit cost payment is also an issue, as the most commonly prescribed IUC is not only licensed as a contraceptive method, but also a treatment for menopausal symptoms, which is a condition that it paid for by the CCG. Therefore there needs to be further investigation as to how best to commission treatments that can benefit more than one commissioning organisation. This requires further exploration. EMERGENCY CONTRACEPTION
Whilst access to oral emergency contraception is provided throughout the county at weekends as well as weekdays, access to emergency coils is currently limited to weekday provision, and may require significant travel. In addition the most vulnerable often do not have the means of independent travel. There are pathways between pharmacies and ISHS and GPs however it is often not practical for a rural GP to offer an emergency IUD. There is also a pathway for an ‘out of hours' service provided by Northumbria Healthcare Trust gynaecology however this is a costly resource. It would be useful to ascertain how often the ‘out of hours' service has been used in order to review provision. GENERAL CONTRACEPTIVE PROVISION IN GENERAL PRACTICE
There is a lack of data available about the general contraceptive provision in primary care, which is part of the GP contract with NHS England. However, the GP prescribed LARC rate in Northumberland is significantly higher than the national and regional averages, falling into the top 10% of local authorities nationally. COMMUNITY CONTRACEPTION
CASH services are currently offered within the ISHS on an appointment and drop-in basis. Whilst some contraceptive clinics are currently provided during the evenings, these are only in the South East area, so the population in the North including Alnwick and Berwick and those in the West have no access to evening sessions, without incurring significant travel. There is a short session on a Saturday based in Blyth, and no service on a Sunday. There is little information about weekend contraceptive provision in Primary care. There may be scope to develop local community pharmacy provision further beyond the scope of EHC. Whilst 12 out of 14 secondary schools provide access to the ISHS in order to provide a weekly drop in service it is for a limited time period (usually up to 2 hours per week). The 2 schools which do not provide access are based within Blyth and Bedlington, where there are higher rates of need. These schools however provide awareness of community services and are committed to providing bespoke SRE. Most ISHS nurses are trained to provide all LARC methods but currently school nurses have limited training and can only provide condoms. However there are currently plans for the school nursing service to provide a pregnancy testing and EHC service in all secondary schools in Northumberland to support the Sexual Heath Drop In service. SEX AND RELATIONSHIPS EDUCATION
Northumberland schools play an important contribution in influencing and developing young peoples' sexual health and wellbeing through their responsibility to provide effective SRE. Higher Education establishments also have a key role to play in ensuring that students have access to sexual health information, advice and services. Whilst most schools are supportive of partnership working a small minority are more cautious in their approach. CERVICAL SCREENING
There is a need to improve uptake for cervical screening, particularly for younger women aged 25 -34 years and older women aged 55 and over. TEENAGE PREGNANCY
There should be a continued focus on reducing teenage conceptions. The current Teenage Pregnancy work programme requires updating however there is still a commitment and passion to deliver on the agenda. Careful monitoring of conception rates alongside termination of pregnancy rates must be maintained. PSYCHOSEXUAL SERVICES
The extent of population need and the patient pathway for these services is not fully understood and sexual difficulty can be caused through physiological, psychological factors, or both. Further detailed exploration by commissioning partners would assist in future service planning STERILISATION AND VASECTOMY
The service delivery and patient pathways are not currently understood. This data can be further understood through an improved functioning Commissioner/Provider Strategic Group VOLUNTARY CARE ORGANISATIONS
There is little known about potential VCS contribution to sexual health other than Trinity Youth and Voices Making Choices where there is little data currently available on sexual health outcomes. Further exploration is required through a stakeholder group meeting. BEHAVIOUR CHANGE INTERVENTIONS
Limited social marketing exercises have been undertaken to determine appropriate behaviour change interventions. Future targeted social media campaigns should be a regular topic at the Commissioner/Provider Strategic Group meetings. 8. SERVICE USER INPUT
There is an annual patient satisfaction survey within the ISHS undertaken by providers which regularly indicates high levels of satisfaction. A questionnaire was distributed in paper format to GUM/community health clinics and youth clubs across Northumberland in 2013. There were 300 respondents in total, 200 from the GUM clinic, with 68% of respondents from the Blyth clinic. Additional questions were attached to the GUM clinic survey. 59% were aged 16-24, male/female split was 30%/70%, 94% were heterosexual and 98% were white. Respondents rated the GUM/clinic they were using very highly, with the main criticism being waiting times. A countywide on-line survey via NCC's website in 2014 secured feedback from 300 respondents, of whom the largest age group was the 45 – 64 age group, and the male/female split was 33%/67%. Most respondents had heard of the majority of available services however fewer than 50% had heard of the C-card scheme, sexual health drop-ins, school/college or MESMAC, which are age/gender specific. This may have been due to the age range of the respondents. Females were more aware than males, and awareness declined with age. GP Practice was preferred for contraceptive services and the GUM clinic was preferred for STI testing, sexual difficulty and free condoms. Pharmacy was a close second for emergency contraception and pregnancy testing. Younger people chose Northumberland clinics, whilst older respondents preferred North Tyneside and Newcastle, whilst most males chose Newcastle whilst females chose Northumberland. The main reason for choosing a clinic outside Northumberland was ‘close to home'. 90% felt it was easy to get to GUM clinics, 10% had issues with either parking or availability of public transport. GP practices had been attended for contraception by respondents in towns across the county. 81% rated the services ‘good' or ‘very good', 25% thought that the opening hours were not accessible with evenings and weekends preferred. 80% rated the services in pharmacies as ‘good' or ‘very good' Personal protection: (multiple answers) almost 80% said they used condoms, followed by 21% female condom. However, almost 16% said they did not use anything. Of those who used protection, only 53% said they used them every time. 9. RECOMMENDATIONS
Table 6. Recommendations for considerations by Commissioners
Clinical
NHS England
County Council
Area Team
Explore effective ways of engaging service users and community groups in the delivery of sexual health services Ensure patient satisfaction surveys are undertaken by providers Ensure clear patient pathways to and from the ISHS to ensure safe and seamless patient journeys Ensure increased partnership working between key organisations, agencies and community groups with the ISHS Increase social marketing exercises in order to determine appropriate behaviour change interventions and accessible services in line with national campaigns Increase sexual health promotion outreach work, especially for vulnerable groups: BME groups, refugees and asylum seekers, looked after children, youth offenders, those with learning disabilities, sex workers, drug and alcohol users, etc. Engage local communities to act as champions and role models to encourage involvement in sexual health promotion and HIV testing activities Produce sexual health promotional material in partnership with local communities that are tailored to their needs using (where appropriate) nationally developed materials Consider the teenage pregnancy agenda and ensure that those at risk of under 18 conceptions are identified with early help and support Support schools in their responsibility to provide high quality SRE and ensure provision of high quality SRE out of school in conjunction with the school nursing service, outreach services, youth service, looked after children and teenage pregnancy initiatives Run programmes to increase self-esteem, communication and negotiation skills targeted at young people at risk of poorer sexual health outcomes SRE at school and in the community should also raise awareness of sexual violence and rape. This should include partnership working with the local police Deliver collaborative, holistic and integrated harm reduction interventions that specifically target the most vulnerable communities Enhance cervical screening awareness, particularly across specific population groups and improve cervical screening pathways Ensure that pathways for sterilisation and vasectomy services Develop comprehensive and standardised data collection for all services and a memorandum of understanding to share relevant data Further innovative ways of improving access to LARC and EHC should be explored in order to maintain focus on reduction in unplanned conceptions Review the current delivery of all sexual health commissioned services to ensure cost-effective delivery, promote integration, quality, value for money and innovation in the further development of sexual health interventions and service An assessment of the training and education needs for local primary care teams in order to enable them to confidently undertake risk assessments and treatments should be considered as a mechanism for improving access to services Prevention efforts, such as increased STI testing and HIV testing should be sustained and continue to focus on groups at highest risk Ensure Equality Impact Assessments are regularly undertaken by all providers and reported upon Continue embedding chlamydia screening in primary care and sexual health services which emphasise regular repeat screenings as appropriate Continue focus towards achieving a chlamydia diagnosis rate of at least 2,300 per 100,000 15-24 year olds Explore the provision of GP enhanced care for HIV in primary Review patient pathways for psychosexual counselling Develop coherent HIV testing policy which increases the accessibility and availability of HIV testing in acute trusts, primary care and community outreach services that is targeted at specific risk groups Support women with unwanted pregnancies to make informed decisions about their options as early as possible Ensure STI (including HIV) testing as well as contraceptive services are provided by TOP services Develop Sexual Health Strategy and commissioning action plan List of Abbreviations
Black and Minority Ethnic Contraception and Sexual Health Clinical Commissioning Group Chlamydia Activity Dataset Emergency Hormonal Contraception Emergency Hormonal Oral Contraception Female Genital Mutilation Gonorrhoea Infection Enhance Gonorrhoea Surveillance General Medical Services Genito Urinary Medicine Genito Urinary Medicine Clinical Activity Data Human Immunodeficiency virus Health Needs Assessment Human Papilloma Virus Health and Social Care Information Centre Integrated Sexual Health Services Intrauterine Contraception Intrauterine Devices and Systems Long Acting Reversible Contraceptive Lower Super Output Area Medical Foundation for HIV & Sexual Health Middle Super Output Area Men who have Sex with Men Nucleic Acid Amplification Test National Survey of Sexual Attitudes and Lifestyles Northumberland County Council National Chlamydia Screening Programme Northumbria Healthcare Foundation Trust National Institute for Health and Care Excellence Office for National Statistics Post Exposure Prophylaxis Post Exposure Prophylaxis following Sexual Intercourse Public Health England Public Health Outcomes Framework Pelvic Inflammatory Disease Royal College of Obstetricians and Gynaecologists Subdermal Implants Sexual Health in Northumberland Sexual Health Needs Assessment Sexual Health Services Sex and Relationship Education Sexually Transmitted Infection Termination of Pregnancy Voluntary Care Organisations Violence Indicator Profiles for England Resource REFERENCES
[1] PHE, "Making It Work," Public Health England, 2014. [2] Department of Health, "A Framework for Sexual Health Improvement in [3] Department for Education and Employment, "Sex and Relationship Education Guidance," DfEE Publications, Nottingham, 2000. [4] WHO, "Developing Sexual Health Programmes - a framework for action," 2014. [5] Mercer C et al., "Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)," The Lancet, vol. 382, pp. 1781-94, 2013. [6] Hartney T et al., "Evidence and resources to commission expanded HIV testing in priority medical services in high prevalence areas," Health Protection Agency, London, 2012. [7] Health Protection Agency, "Time to test for HIV: Expanding HIV testing in healthcare and community service in England," Health Protection Agency, London, 2011. [8] NICE, Increasing the uptake of HIV testing among Black Africans in England (PH33), 2011. [9] NICE, Increasing the uptake of HIV testing among men who have sex with men (PH34), 2011. [10] Lorenc T et al., "Promoting the uptake of HIV testing among men who have sex with men: systematic review of effectiveness and cost-effectiveness," Sexually Transmitted Infections, vol. 87, no. 4, pp. 272-8, 2011. [11] Carson C et al., "Effect of pregnancy planning and fertility treatment on cognitive outcomes in children at ages 3 and 5: longitudinal cohort study," BMJ, vol. 343, p. d4473, 2011. [12] D. Kirby, "Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases," The National Campaign to Prevent Teen and Unplanned Pregnancy, Washington DC, 2007. [13] Santelli J et al., "Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use," American Journal of Public Health, vol. 97, no. 1, pp. 150-6, 2007. [14] Mercer C et al., "Building the bypass - implications of improved access to sexual healthcare," Sexually Transmitted Infections, vol. 88, pp. 9-15, 2012. [15] A. McGuire and D. Hughes, "The economics of family planning services: a report prepared for the Contraceptive Alliance," Family Planning Association, London, 1995. [16] G. Bell and J. Potterat, "Partner notification for sexually transmitted infections in the modern world: a practitioner perspective on challenges and opportunities," Sexually Transmitted Infections, vol. 87, pp. ii34-ii36, 2011. [17] Department of Health, "Developing strong relationships and supporting positive sexual health," 2014. [18] F. N. e. al, "Projected lifetime healthcare costs associated with HIV infection," in Presented at the British HIV Association, London, 2012. [19] Public Health England, "Addressing Late HIV Diagnosis through Screening and Testing," PHE, 2014. [20] British HIV Association, "British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012," HIV Medicine, vol. 15, no. Suppl. 1, pp. 1-85, 2014. [21] Bayer Healthcare, "Contraception Atlas 2013," 2013. [22] NICE, Long acting reversible contraception (CG30), 2005. [23] M. F. &. S. HEALTH, "HIV in Primary Care - An essential guide for GPs, practice nurses and other members of the primary healthcare team," MEDICAL FOUNDATION & SEXUAL HEALTH, no. 2nd Editoin, 2012. [24] Downing J et al., "Prevention of sexually transmitted infections (STIs): a review of reviews into the effectiveness of non-clinical interventions," Centre for Public Health, Liverpool, 2006. [25] NICE, Prevention of sexually transmitted infections and under 18 conceptions (PH3), 2007. [26] Dolan P et al., "Mindspace: Influencing behaviour through public policy," Institute for Government, 2010. [27] I. Bozicevic and M. Donoghoe, "Ongoing issues related to sexually transmitted infections (STIs) including HIV/AIDS in the population over the age of 50 in the WHO European Region," Entre Nous, vol. 77, pp. 22-3, 2013. [28] MEDFASH, "Recommended standards for sexual health services," Medical Foundation for AIDS and Sexual Health, London, 2005. [29] Public Health England, Addressing Late HIV Diagnosis through Screening and Testing: An Evidence Summary, London: Public Health England, 2014. [30] W. W. H. Organisation, "Developing Sexual Health Programmes - a framework for action," 2014.


Other Young Peoples Sessions (These sessions are only for pupils enrolled at the school)
Bedlingtonshire High Duchess High / Alnwick Pop In Northumberland College Northumberland College SEXUAL HEALTH SERVICE Kirkley Hall College Tel: 01670 515151 Josephine Butler, Church of England Academy Appointments and Advice The Blyth Academy Cramlington High Integrated Sexual Health & Coil Procedure Contraception and/or genito-urinary screening or sexual infection Northumberland College Week 1 10:15am - 2:45pm (Appointments Only)
Week 2 1:30pm - 3:00pm (Appointments Only)

James Calvert Spence Quick Screens weekly 11:00am - 12:00pm (Appointments Only)
Morpeth Integrated Sexual Health (Queue & Wait)
Contraception and/or genito-urinary screening or sexual infection Northumberland College Blyth Integrated Sexual Health & Coil Procedure Contraception and/or genito-urinary screening or sexual infection Northumberland College 1:00pm—3:00pm Queue & Wait
4:00pm—6:30pm Queue & Wait

Northumberland Sexual Health Session Addresses
4:00pm - 6:30pm Appointments only
Alnwick Infirmary Berwick Infirmary The Hotspur Unit Amble Youth Project Old Cheviot Ward Young Peoples Drop In (Under 25s)
Infirmary Square (Contraception and Chlamydia & Gonorrhoea Screening only) Berwick Upon Tweed The Health Centre Day Surgery unit Integrated Sexual Health Young Peoples Drop In (Under 25s)
Greencroft Avenue Contraception and/or genito-urinary screening or sexual infection Blyth Community Hospital Bedlingtonshire Medical Group (The Thomas Knight Day Unit Contraception and Sexual Health (Appointments Only)
Lintonville Terrace Cramlington CaSH Lynemouth Drop In Cramlington Health Centre Wellway Medical Group Young Peoples Drop In (Under 25s)
(Contraception and Chlamydia & Gonorrhoea Screening only) Wansbeck General Shiremoor Resource Centre Version 2 September, 2014 S:Drive/SH General/Service/Service/signposting 2014
Thursday
Alnwick Infirmary Genito-urinary Medicine (Appointments Only)
Integrated Sexual Health & Consultant complex cases (Appointments only)
Contraception and/or genito-urinary screening or sexual infection screening Integrated Sexual Health (Appointments Only)
Sex Therapy—North Tyneside (Appointments Only)
9:00am to 4:00pm Contraception and/or genito-urinary screening or sexual infection screening Quick Screens (Appointments Only)
Alnwick Infirmary Integrated Sexual Health & Coil Procedure (Appointments Only)
Contraception and/or genito-urinary screening or sexual infection screening Integrated Sexual Health (Appointments Only)
Contraception and/or genito-urinary screening or sexual infection screening Contraception and Sexual Health (Appointments Only)
Quick Screens (Appointments Only)
3.00pm to 5.45pm Sex Therapy—Northumberland (Appointments Only)
Morpeth Complex Cases and Coil Procedure (Appointments Only)
3:30pm to 6:30pm Integrated Sexual Health & Coil Procedure Pregnancy Options Clinic (Appointments Only)
Contraception and/or genito-urinary screening or sexual infection screening 3:30pm to 4:30pm 2:30pm - 4:30pm Queue & Wait
Hexham General Integrated Sexual Health, Consultant complex cases & Coil Procedure Coil Procedure 2:30pm - 4:30pm Appointments Only
(Appointments Only)
4:45pm—6:15pm Queue & Wait
4:00pm to 6:00pm Contraception and/or genito-urinary screening or sexual infection screening Young Peoples Drop In (Under 25s)
Integrated Sexual Health (Appointments Only)
4:45pm to 5:45pm Contraception and Chlamydia & Gonorrhoea Screening only Contraception and/or genito-urinary screening or sexual infection screening Wednesday
Contraception and Sexual Health (Appointments Only)
Integrated Sexual Health (Queue & Wait)
9:00am - 11:30am Contraception and/or genito-urinary screening or sexual infection screening Integrated Sexual Health (Queue & Wait)
Contraception and/or genito-urinary screening or sexual infection screening Integrated Sexual Health & Coil procedure Contraception and/or genito-urinary screening or sexual infection screening Quick Screens and Emergency Contraception (Queue & Wait)
10:00pm -12:00pm Appointments Only
1:30pm - 3:00pm Queue & Wait
Pregnancy Options Clinic (Appointments Only)
Contraception and Sexual Health & Quick Screens (Queue & Wait)
1:30pm to 2:30pm General Hospital Coil Procedure and Implant Removals (Appointments Only)
Contraception and Sexual Health & Coil Procedure (Appointments only)
Saturday
Contraception and Sexual Health & Coil Procedure (Appointments Only)
3:15pm to 5:15pm Contraception and Sexual Health & Quick Screens (Queue & Wait)
Integrated Sexual Health Young Peoples Drop In (Under 25s)
4:00pm to 6.00pm Contraception and/or genito-urinary screening or sexual infection screening Contraception and Sexual Health (Appointments Only)
QUICK SCREENS - You are suitable for this clinic if you have NO concerns about your Sexual
4:00pm to 6:00pm Health and would just like a check up. The test does NOT require you to get undressed and be examined. For Men—Urine Test Sex Therapy—Northumberland (Appointments Only)
For Women—Self Taken Swab 4:30pm to 8:00pm Blood tests are also recommended for both men and women

Source: http://committeedocs.northumberland.gov.uk/MeetingDocs/8968_M1111.pdf

Ley de actos y procedimientos administrativos del estado de yucatÁn

Ley publicada en el Diario Oficial del Gobierno del Estado de Yucatán el 07 de diciembre de 2009 GOBIERNO DEL ESTADO PODER EJECUTIVO DECRETO NÚMERO 247 C. IVONNE ARACELLY ORTEGA PACHECO, GOBERNADORA DEL ESTADO DE YUCATÁN, CON FUNDAMENTO EN LOS ARTÍCULOS 38, 55 FRACCIONES II Y XXIV DE LA CONSTITUCIÓN POLÍTICA DEL ESTADO DE YUCATÁN Y 14 FRACCIONES VII Y IX DEL CÓDIGO DE LA ADMINISTRACIÓN PÚBLICA DE YUCATÁN, A SUS HABITANTES HAGO SABER: QUE EL HONORABLE CONGRESO DEL ESTADO DE YUCATÁN SE HA SERVIDO DIRIGIRME EL SIGUIENTE DECRETO: "EL CONGRESO DEL ESTADO LIBRE Y SOBERANO DE YUCATÁN, CONFORME A LO DISPUESTO EN LOS ARTÍCULOS 30 FRACCIÓN V DE LA CONSTITUCIÓN POLÍTICA; 97, 150 Y 156 DE LA LEY ORGÁNICA DEL PODER LEGISLATIVO Y 3 DE LA LEY DEL DIARIO OFICIAL DEL GOBIERNO, TODAS DEL ESTADO, EMITE LA LEY DE ACTOS Y PROCEDIMIENTOS ADMINISTRATIVOS DEL ESTADO DE YUCATÁN, EN BASE A LA SIGUIENTE:

Table 4

Opioid Prescribing Tool Kit Nathaniel Katz, MD, MS Tufts University School of Medicine Boston, MA Analgesic Research Needham, MA © Nathaniel Katz, MD, MS 2006. All rights reserved. Funded in part by the Massachusetts Department of Public Health. Production support provided by Fusion Medical Education, LLC, Wakefield, MA