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Chlamydia screening at the crossroads

11 Jan, 10 | by Jackie Cassell, Editor of STI

As financial screws tighten, and a general election approaches, British clinical readers are expecting lean times ahead.   Services for sexually transmitted infections (STI) are unlikely to get major billing in party manifestoes, and political support tends to be driven by committed individuals rather than public demand.

These are particularly interesting times for England’s National Chlamydia Screening Programme (NCSP).  The programme has been the subject of a report by the National Audit Office, followed by a hearing of Parliament’s Public Accounts Committee before the Christmas break.

The NCSP was announced in 2003, and differed from pilot studies in several respects.  Both English pilots(1,2,3) had achieved high rates of coverage within their single year of operation, with general practice a predominant setting, and using some form of payment for general practitioners who participated, while only one(3) had included males in the target group.

During the financial year April 2008-2009 an estimated 15.9% of England’s 6.7M 15-24 year old population had been tested for Chlamydia outside specialist genitourinary medicine clinics – still far short of the estimated one third which was achieved in the pilots and thought to be needed to achieve a real impact on incidence.    However, whatever happens now the programme will continue to have a major impact on the organisation of sexual health services.  The dissemination of testing into family planning (contraception) clinics, other young people’s services and increasingly into general practice has already mainstreamed awareness of STIs among the public and professionals. The next few months will be crucial in defining public policy on the balance and relationship between the NCSP (simple service, high throughput) and specialist STI services (complex and expensive, and focussing on the needs of individuals of higher than average risk behaviour or worse than average luck).

The NCSP was criticised by the National Audit Office(4 ) for multiple and weak branding, disorganised and cost-inefficient commissioning, and highly variable partner notification (and even treatment) rates. The report is definitely worth a read, along with its sister publication – a report on the NCSP to the Department of Health by Dr Ruth Hussey. The NCSP was implemented in a period of increasing devolution of a wide range of healthcare resource decisions to local areas, with pressure applied where needed by blunt instruments such as the “Vital Signs Indicator” which last year set a standard of 17% coverage for the NCSP .  In this respect, its difficulties  are likely to be a wider sign of the times - as suggested by the Chair of the Public Accounts Committee, who remarked in closing: “What went wrong? You ploughed ahead with local, fragmented implementation, the programme has been inefficient, it has wasted public funds and each programme has been buying its own kit, devising its own marketing and websites.

Although the Public Accounts Committee’s recommendations are not yet published, a flavour of what we can expect can be inferred from a webcast of the hearing at http://www.parliamentlive.tv/Main/Player.aspx?meetingId=5227 or, if you prefer the written word, at http://www.publications.parliament.uk/pa/cm/cmpubacc.htm#uncorr

A more coherent branding and commissioning of the NCSP will have implications for the branding, and prioritisation, of more specialist STI services. Clinicians and providers will need to think and advocate long and hard for a locally effective the future balance between the NCSP (whatever form it may take), and the broader picture of services for STIs, including specialist services. Who and what will they be for, if everyone offers a yearly chlamydia test?

4. National Audit Office:  Young People’s Sexual Health. http://www.nao.org.uk/publications/0809/young_peoples_sexual_health.aspx
5. Dr Ruth Hussey.  Review of the National Chlamydia Screening Programme.  Crown publication, London, 2009. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108285
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