Dr Marcus Bicknell explains how a mobile phone texting service is allowing teenagers to overcome their embarrassment and seek help for sexual health problems
Teenage pregnancy has almost become the norm in some parts of Nottingham. Certain areas have some of the highest teenage pregnancy rates in Europe. The social implications of teenage pregnancy can be quite devastating, especially in poorer communities. Norcomm PBC group agreed that tackling this should be a priority.
We know that adolescents are a hard-to- reach group. They can feel embarrassed about going to see a doctor and they may be worried about confidentiality.
So Norcomm – covering 17 GP practices, 120, 000 patients and over 70 GPs – started to look into ways of addressing this problem and came up with the Textual Health project in the summer of 2008. We wanted to develop a scheme whereby the young person can send a text about sexual health issues, get a quick response with either advice or signposting, meet a sexual health worker if necessary and be connected to the appropriate part of the sexual health service.
In no way does this project encourage young people to engage in sexual activity but it’s there to help them if they have questions about it. Queries can include contraception, chlamydia testing, STD testing, emergency contraception and pregnancy testing, along with other issues. We strongly advocate that young women consider long-acting hormonal contraception to prevent teenage pregnancy.
Getting off the ground
Nottingham City PCT has been very supportive in this, as it has been with all our PBC projects. We also engaged the support of key stakeholders and our local MP, Graham Allen, who is a great advocate of encouraging young people to develop their personal, social and life skills before becoming parents.
We launched the idea in December 2008. The PCT was very careful about getting the tendering process and specification documents right and it took around a year from launch of the idea to interviewing for providers.
The tendering process was not straightforward, as the scheme was so innovative the PCT decided to split the tendering in two – Textual Health and sexual health clinics.
Textual Health was the first component. We had a lot of interest from potential providers and invited four organisations to interview in late 2009. We chose the Terence Higgins Trust (THT), which started to provide the service a couple of months ago and is proving a good partner.
The second component is to provide sexual health clinics that are appealing to young people. Brook Birmingham was successful here, and this part of the project is about to launch two clinics.
NHS Nottingham City already commissions a number of contraceptive and sexual health clinics, some of which are aimed specifically at young people. The Brook clinics are located close to schools and other places that young people use, with clinic times starting after schools finish and marketing materials targeted at young people. They have a direct link with the Textual Health service and this should prove a more integrated approach to providing sexual health services to young people.
In our efforts to reach out to this group, we decided to advertise Textual Health and chlamydia screening on the back of buses. Matt Gregory who works locally for the THT has also been going out into youth groups and schools giving out posters and credit-card-sized cards with the number on. We are even considering putting the scheme onto social networking sites.
We have had some fantastic graphics produced by the THT to make it attractive to young people.
Norcomm has been able to use freed-up resources – mainly from savings in the prescribing budget – to invest in the service.
Textual Health is costing around £80,000 for the 12-month pilot, including set-up and running costs.
The cost of the sexual health clinics is about £20,000 per clinic for one three-hour session each per week. This again includes set-up and running costs.
There are a number of benchmarks for THT staff to reach in terms of the number of young people they are in contact with at each tier of the service.
Brook will give a detailed breakdown of activity such as how many teenagers are being given which forms of contraception, but the key issue will hopefully be a reduction year on year of the teenage pregnancy rate.
Nuts and bolts
The scheme covers the Aspley, Bilborough, Basford and Bestwood wards of Nottingham City.
The text service is available round the clock. The text is sent by the teenager and goes to the THT information service. The young person gets an automatic response to acknowledge they have reached the Textual Health Service. If they have asked a question such as where to get emergency contraception they will either get a response from advisers at the main hub or, if they need something more local or specific, they will get a response from Matt Gregory, sexual health adviser at Textual Health. The next level is to offer them a face-to-face consultation, though often they prefer to remain anonymous and just interact by text.
One of the issues in persuading a hard-to-reach group such as teenagers to actively seek out and benefit from the best forms of healthcare is incentivising them. I was aware of some projects in Australia that pay people to have contraceptive implants. The ethics of paying people to receive treatment are complex so we didn’t want to do that, but decided the best way to incentivise young people to access the service would be by offering top-up vouchers for their phones to help them to keep in contact.
It makes sense that if teenagers need to keep in touch with healthcare they need the resources to do it, so by offering top-up vouchers we are giving them the means. At the moment they only get the top-up voucher if they have a face-to-face consultation but we are adapting the scheme as we go along and will take a flexible approach.
In the first three months of the service we averaged about 40 text contacts per month. Two months into the service, 17 young people had been referred to contraception services.
With respect to the young people’s sexual health clinics we expect 26 contacts per month per clinic in the first six months, increasing to 34 contacts per month per clinic in the second six months.
The project didn’t set out with a savings target, which would have been impossible to measure anyway given the number of other teenage pregnancy initiatives in Nottingham City. Its purpose is to evaluate whether text messaging is an effective way of providing sexual health advice. The Textual Health contract specifies 600 unique text contacts and 95 clients having used the face-to-face support service. However, about three months in it appears that what clients value the most about Textual Health is its anonymity which is at odds with the face-to-face support. We are therefore working with THT on alternative ways of using the face-to-face capacity.
Nottingham already had established sexual health services but it was recognised that we had teenage pregnancy hotspots and low chlamydia screening uptake. I am sure that the energy around our project has supported the existing services and we all recognise the importance of teenage sexual health. We have seen a significant fall in teenage pregnancy rates in the last two years, of around 15% since the service was first planned. Instead of having some of the worst figures in Europe, Nottingham City is now 11th in the UK and falling – though we realise there could be variation in these figures over time.
Now Textual Health and the Brook clinics are up and running we are hoping that we will see an even greater improvement.
Another benefit has been the interest from other sectors. For example school nurses are very interested in what we are doing, and the practices involved have become more interested in offering sexual health services. Most of the practices in Norcomm are able to provide a wide range of contraceptive services including Implanon.
A huge amount of the work is about changing the culture in this community, where you see pregnant 15-year-olds whose mothers were themselves 17 when they had them. We need to show that isn’t the best choice, it’s better to wait and mature. We have to show the benefits of that to the community.
I think this scheme is truly innovative. When we started there was nothing else around that tried to reach young people in the same way.
At the moment this scheme is running as a 12-month pilot. If the evaluation of the pilot goes well we hope that the service will be mainstreamed and commissioned directly by NHS Nottingham City (go to practicalcommissioning.net to see the evaluation protocol). If it is re-commissioned I expect to see teenage pregnancy figures continue to fall. I really do hope that we can effect real and meaningful change.
We are prepared to be flexible and adapt the scheme as necessary. For example, I heard from some young people recently that most of them are on phone contracts so a top-up voucher may not be helpful. We may have to adapt this element.
This scheme could work all over the country – the Textual Health service is an exciting and innovative way to reach young people and the Brook component of having a clinic that is targeted and tailor-made to this group is really important.
Dr Marcus Bicknell is a GP in Nottingham and chair of Norcomm PBC consortium
From left: Dr Marcus Bicknell, PBC manager; Simon Oliver, PBS officer; Charlotte Maher and Matt Greogry of the Terence Higgins Trust Dr Marcus Bicknell and team Dr Marcus Bicknell How it works
The purpose of the service is to increase awareness and use of local contraceptive and sexual health services. It offers non-clinical advice and support and signposting information to local services. A secondary aim is to encourage young people to make use of services in general practice.
The overall service encompasses three levels of service with clients moving from one level to another depending on the provider’s assessment of the clients’ advice needs.
• Level 1 – Clients requesting advice on where to obtain contraceptive or sexual health services will receive a personal text reply.
• Level 2 – Follows up those with specific concerns or who have texted several times, checks they’ve followed the signposts and offers texted encouragement and praise for doing so.
• Level 3 – gives more intensive social support. Sexual health workers meet face to face with clients at risk-assessed and approved venues to engender self-empowerment so that they feel able to use existing services. Workers can accompany clients to appointments and will in any case follow up how clients are later.texting teens