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Targeting teenagers with a drop-in clinic

A nurse-led clinic run from a GP practice is offering teenagers sexual health advice. Kate Burton describes how she championed the service

A nurse-led clinic run from a GP practice is offering teenagers sexual health advice. Kate Burton describes how she championed the service

Field House Medical Centre is unique in North-East Lincolnshire in that it has a drop-in nurse-led clinic for contraceptive and sexual health services running Monday to Friday.

The service started in the wake of the Government's teenage pregnancy strategy nearly 10 years ago and has evolved into a one-stop shop. We have increased the uptake of contraceptive services year on year and are now doing the same with sexual health screening. GPs at the surgery praise how the service frees up their time.

Why a drop-in clinic?

North-East Lincolnshire has a history of high teenage pregnancies (in 1998 it was 69.8 per 1,000 15- to 17-year-olds, compared with the England average of 46.6).

The idea of the drop-in clinic came about following a reduction in the number of local community-based family planning clinics. These were not easily accessible in terms of location and opening times, and not every clinic offered a full range of contraception.

41193342As one of these clinic's family planning nurses, I wanted to champion an equitable service for all, regardless of age, that would be at a regular time and in an accessible place every day.

The practice manager at Field House Medical Centre at the time felt patients were being poorly served and that the centre could improve its service, building on the foundations of its existing weekly drop-in clinic.

I was employed by the practice with the remit of providing a contraceptive service daily, as part of the practice's wave one PMS contract in 1999.

What preparation was needed?

Our main challenge was promotion. I made signs and business cards for display in the surgery, including posters emblazoned ‘Family planning nurse available NOW'.

Our GPs encouraged patients requesting contraception to see the nurse, and health visitors referred new mothers. At the time we were still doing school leaver immunisations and health checks, and this proved an excellent way of introducing our service to every 15-year-old. Teenagers soon got the message and when they found they could bring a friend with them for moral support, they came back time and again.

Our PCT supplied us with pregnancy testing kits and free condoms to hand out.

How does the drop-in clinic run on a day-to-day basis?

The service operates in typical after-school hours – 4.15-6.15pm, Monday to Friday – but patients can also make an appointment during the day if needed.

Four enthusiastic nurses staff the clinic, with one or two working each session. All have family planning certificates and sexual health qualifications and the practice has also supported them through specialist training such as HIV courses.

Two staff are nurse practitioners able to prescribe independently, and other prescriptions are signed by GPs. We primarily use guidelines from the Royal College of Obstetricians and Gynaecologists' faculty of sexual health and reproductive healthcare. We offer a full range of contraception directly or from practice GPs (see box).

Attendance has risen to nearly 4,000 per year (see graph, below right). Clients are mostly women, aged 13-50, and they do not have to be registered at the practice to be seen for contraception.

We see a varying number of teenagers each evening, and numbers increase when contraception is on the agenda at school, when the chlamydia screening team have been into colleges, and during school holidays.

How are confidentiality issues dealt with?

Generalisations are often made about teenagers not being willing to access sexual health care from GP practices. Field House has tried to overcome these by training all staff to be aware of RCGP and RCN guidelines on confidentiality of teenagers and displaying ‘Here to listen not to tell' posters.

We have found that by running the clinic alongside everyday surgery clinics, patient anonymity is maintained and that if they have confidence in the healthcare professional they will access the service no matter where that service is.

Initial consultations with under-16-year-olds always include an explanation of their right to confidentiality unless we feel they, or others, are at risk of abuse (we have referred cases to the child protection team). We also encourage teenagers to discuss contraception needs with a parent or carer if they are able to, in line with the national Fraser guidelines.

Having gained their confidence, teenagers will present with diverse problems, ranging from self-harm to sore throats, which are referred on to more appropriate team members.

Teenagers not registered with us, with issues other than contraception, are referred to their own practices and, with their permission, we liaise with their practice nurse and make follow-up checks on attendance.

How are STIs handled?

Last year we became the first surgery in North-East Lincolnshire to become a chlamydia screening centre, offering all under-25s, whether registered with us or not, the opportunity to be screened using urine samples. The screening office receives the results and organises treatment and contact tracing, taking this burden away from us.

By offering screening during the contraceptive clinic, we aim to remove any stigma and embarrassment and normalise STI screening. Last year we collected 241 ‘asymptomatic' samples and had 22 positive results, which the chlamydia screening team followed up.

Who are patients referred to?

We refer clients to other services, such as:

• termination assessment clinic

• sexual health clinic for complex STIs

• ultrasound scans, for pre-gynaecology assessment or unseen IUCD threads

• early pregnancy assessment unit

• counsellors and community mental health team

• midwifery service

• DEXA scan appointments, for long term users of Depo-Provera

• GPs, for IUCD/IUS fitting and implant fitting

• school nurses, with the teenager's permission

• enuresis team

• health visitors for post-natal problems.

What is the approach to LARC?

Long-acting reversible contraception has been promoted by the Government as a way of reducing teenage pregnancy and we have increased use every year, with latest data showing it made up 19.5% of prescriptions compared with oral methods – close to the national average of 21% in 2006/7.

What are the benefits of the service?

Patients receive:

• an accessible service – in the town centre, on key bus routes and open every weekday

• a full range of contraception

• empowerment with knowledge and wherewithal to prevent exposure to STIs and unintentional pregnancy.

Anecdotally, other healthcare professionals refer teenage clients to us, as it is easy to remember when our clinic runs and they know their clients will get excellent care and attention.

Benefits for staff include extended skills, empowerment and job satisfaction. I am also a clinical mentor for a local university family planning course and we offer clinical placements – the only surgery in the area able to do this. We don't receive any financial remuneration for this, just the satisfaction of training future family planning nurses to our standards.

Educating our own staff is a continuing priority, such as reminding receptionists to treat requests for emergency contraception urgently by offering an immediate nurse appointment.

What has been the impact on reducing teenage pregnancies?

Our impact on reducing teenage pregnancy is debatable, as the North-East Lincolnshire rate has changed little over the years (from 69.8 in 1998 to 64.5 per 1,000 15- to 17-year-olds in 2006). Referrals for termination are static for under-18s but have increased by more than 60% in those aged 18 and over, despite ease of access to contraception.

Anecdotally this seems to be due to more women feeling that they can access a termination, where before they would have continued with their unplanned, unwanted pregnancy. Although their contraception may have failed, or not existed, we have empowered them to be able to address an unplanned pregnancy, so a rise in termination rates cannot always be judged a failure in the service.

What is rewarding is that women who have attended our clinics for several years are now bringing their daughters to us for sexual health care and contraception. I feel this shows we are a trusted service.

We have not formally analysed the financial impact of our service, but we are seeing 3,000 patients a year that a GP might have seen, so we are freeing up their time for more complex patients (see box).

What lessons were learned?

As a nursing team we have developed an informal peer support system to cope with challenges. We have faced girls under 15 being pregnant, sexual abuse, unexpected STIs and patients with complex medical conditions who still need contraception.

Discussing sexual wellbeing with a girl of 15 and her partner can be challenging and has to be handled appropriately and sensitively to maintain their confidence and encourage them to return for further advice.

What is the service's future?

Local sexual health services have historically been commissioned through a mixture of funding streams. North East Lincolnshire Care Trust Plus is currently undertaking a sexual health needs assessment and service review, to ensure services are cost-effective and quality assured, to inform a future commissioning strategy.

Field House now has a well-attended, accessible, daily contraceptive service for all ages that has expanded to encompass sexual health.

The clinic would not have worked without dedicated staff, committed to providing a full service. Even in the face of such challenges as staff shortages and floods, we have never been known to close.

Kate Burton is an RGN and nurse practitioner who worked as a family planning nurse in community clinics for more than 10 years, before joining a North East Lincolnshire practice in 1998. Contact her by email at kate.burton@nelctp.nhs.uk

How GPs rate the service

Dr Derek Hopper, senior partner at Field House Medical Centre and honorary secretary of the National Association of Primary Care, says:
‘It has been very effective in delivering contraceptive services to our patients and using the skill mix in the team, freeing up GP time. The service does not require an appointment and ensures immediate access.
Patients feel more comfortable with the service being provided by nurses and consultations offer an opportunity to signpost patients to other services in the surgery or to provide lifestyle and health promotion advice.'

Services offered Nurse practitioner Kate Burton leads the daily service

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