City of York Council

Equalities Impact Assessment

Who is submitting the proposal?

Directorate:		Public Health
Service Area:		Public Health
Name of the proposal:		Commissioning of Sexual Health Services from 2024
Lead officer:		Philippa Press/Anita Dobson
Date assessment completed:		November 2022
Names of those who contributed to the assessment :
Name	Job title		Organisation	Area of expertise
Philippa Press	Public Health Specialist		City of York Council	Public Health
Anita Dobson	Nurse Consultant in Public health		City of York Council	Public Health
Feedback from Service user, potential provider and stakeholder survey included.	Community Pharmacists, GP’s Voluntary and statutory organisations, Health Watch		ICB, CYC. Colleges, Universities, Community Pharmacies. Potential providers who provide sexual health services across the region.	A total of 9 potential providers, 24 stakeholders and 125 service users answered the survey’s

Step 1 – Aims and intended outcomes 

1.1

What is the purpose of the proposal? Please explain your proposal in Plain English avoiding acronyms and jargon.

The purpose is to re-commission Sexual Health Services in York. An integrated sexual health service provides patients with open access to confidential, non-judgemental services including STI (Sexually Transmitted Infections) and BBV (Blood Borne Viruses e.g. HIV) testing, treatment and management; the full range of contraceptive provision; health promotion and prevention. This EIA is to ensure that the service continues to provide services to those most in need without any detrimental impact.

1.2

Are there any external considerations? (Legislation/government directive/codes of practice etc.)

Local authorities are mandated to commission comprehensive open access sexual health services, including free STI testing and treatment, notification of sexual partners of infected persons and advice on, and reasonable access to, a broad range of contraception; and advice on preventing unplanned pregnancy, DHSC has produced guidance to assist local authorities to commission these and other sexual health interventions. Reproductive health services that are mandatory and the commissioning responsibility that sits with Local Authorities is set out in the Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013.

1.3

Who are the stakeholders and what are their interests?

Sexual health is not provided by one service alone but is regarded as being a system wide service. GPs, Pharmacists, terminations providers, PSHE coordinators in schools, University welfare services, Sexual Assault Referral Centres (SARCs), domestic violence support providers are all stakeholders in the provision of sexual health services as they are likely to refer clients to services for support. We also know that LGBTQ, ethnic minorities and those with a disability are likely to experience poor sexual health either through stigma, barriers to access etc.

1.4

What results/outcomes do we want to achieve and for whom?  This section should explain what outcomes you want to achieve for service users, staff and/or the wider community. Demonstrate how the proposal links to the Council Plan (2019- 2023) and other corporate strategies and plans.

The EIA is to ensure that the recommissioning of the service will not be of any detriment to those already accessing the service and those who want to access the service. Good Health and Wellbeing and A better start for children and young people are a core components of the Council Plan. The service will support delivery against the three main sexual health Public Health Outcomes Frameworks measures: • Under 18 conceptions • Chlamydia detection (15-24 year olds) • People presenting with HIV at a late stage of infection. These measures are important across all residents but are particularly high amongst those with protected characteristics, those that live in the more deprived areas and young people, creating further inequality. In addition, it will deliver the following outcomes to improve the sexual health in the local population as a whole but based on local needs assessments to recognise risk changes in the population. Sexual and Reproductive Health (SRH) services: · Clear accessible and up to date information about services providing contraception and sexual health services for the whole population including preventative information targeted at those at highest risk of sexual ill health. · Increased uptake of effective methods of contraception, including rapid access to the full range of contraceptive methods including Long Acting Reversible Contraceptive (LARC) for all age groups. · A reduction in unplanned pregnancies in all ages as evidenced by teenage conception and abortion rates. Sexually Transmitted Infection (STI) services: • Improved access to services amongst those at highest risk of sexual ill health. • Reduced sexual health inequalities amongst young people and young adults. • Increased timely diagnosis and effective management of sexually transmitted infections and blood borne viruses. • Repeat and frequent testing of these that remain at risk. • Increased uptake of HIV testing with particular emphasis on first time service users and repeat testing of those that remain at risk. • Monitor uptake of late diagnosis and partner notification. • Increase availability of condoms and safer sex practices. Overarching: • Increased development of evidence-based practice and ensure patient consultation, involvement and development. • Maintenance of research governance and other necessary arrangements to participate in trials e.g. PrEP impact trial. • Ensure that participants receive continued support to be able to access trials through the commissioned service in the event of the service being re-tendered.

Step 2 – Gathering the information and feedback 

2.1	What sources of data, evidence and consultation feedback do we have to help us understand the impact of the proposal on equality rights and human rights? Please consider a range of sources, including: consultation exercises, surveys, feedback from staff, stakeholders, participants, research reports, the views of equality groups, as well your own experience of working in this area etc.
Source of data/supporting evidence		Reason for using
Sexual Health Needs Assessment		This looks at the current and emerging sexual health needs of the population of York. The primary intended outcome of this needs assessment is to inform future sexual health strategies and commissioning decisions over the next three years.
Service User Survey		Disseminated late September with a closing date of 11 November this survey captured the views and experiences of people using our sexual health services. Key points from the survey indicated that most service users preferred to access sexual health services from the Specialist Service rather than from the GP and were more likely to recommend it to friends and family. The majority used the specialist service for contraceptive advice but pregnancy, abortion, sexuality advice was all cited.  The majority of testing for STIs was done in clinic (45%) compared to on-line (35%). Other service user respondents would like to see Cervical Screening and young people’s services as part of the service provision. The survey also provided useful information on how service users would like to access the service and when. Most responses said they had no barriers to access and were happy with how this was managed. Most responders were aged 16 to 24years old with only a few not answering the question. The only age group not represented was 56-59. Females were the largest group pf respondents (55%), followed by males (27%) and non-binary (16%).
Stakeholder Survey.		Stakeholders from a variety of occupations, service and organisations were invited to take part and include respondents from: statutory organisations – CYC and ICB, voluntary organisations MESNAC, IDAS, primary care (GP’s, nurses and pharmacies), education, students union and termination providers. As expected, the majority of responders signposted to other sources of sexual health support as well as providing some specialist support themselves. The majority signposted to the YorSexualHealth website, other websites were mentioned – BASHH and the Faculty being the most common alternatives. 80% of referrals were for sexual health information and advice with 66% signposting for Sexual assault/abuse, 60% for contraception and 47% for emergency contraception. In terms of gap identified lack of drop-in was cited the most, school and community provision (in pharmacy) and more outreach rather than clinical provision was needed. Some of the barriers to access included: its not well known about by young people and that its on a busy street so not very confidential. However, in another question the location of the service was seen as a strength.  Training requirements ranged from refresher on what services are offered and where to specifics regarding LARC.
Potential Providers – event and survey		On 25 October a potential providers event was held online via MS Teams – all the providers from across the region were invited to attend and approximately 7 different providers attended. The event had input from the Director of Public Health, Nurse Consultant in Public Health, and procurement category manager. A mixture of providers responded some could provide the whole service and others would enter into a consortium. None of the respondents thought there was anything that could be omitted from the service spec but some suggestions included a review of the on-line offer, the importance of a collaborative approach, a review of the KPI’s and suggestions on staff utilization. Identified cost pressures included – staffing and pay increases as the main issue.
Potential providers – confidential conversations		Following the event on the 25 October all potential providers were offered the opportunity to have a 121 confidential discussion with us to explore ideas in making this contract viable and will include discussions on: Contract duration Contract structure Service structure  social values Developing a system wide approach LARC provision across the city Two organisations has taken up the offer to do this.
Engagement report		Following completion of the above an engagement report will be written outlining key themes and feedback with no references to individuals or organisations. This will inform future commissioning options, service specification development and feedback on current service provision.
Development of the Service Specification		Following the completion of the engagement phase of this process a service specification will be developed and consulted on. Again, key stakeholders and service users will be able to comment on the impact of this on their service and user groups.  This will further inform this EIA.
Sexual health Needs Assessment		A comprehensive SHNA has been written using the most up to date data from a variety of sources. A separate document is available in full but the main findings where: · As a response to the COVID-19 pandemic, the Government implemented national and regional lockdowns and social and physical distancing measures since March 2020. These measures affected sexual behaviour and health service provision. Interpreting data from 2020 should consider these factors, especially when comparing with data from pre-pandemic years. · Overall, the number of new sexually transmitted infections (STIs) diagnosed among residents of York in 2020 was 960. The rate was 455 per 100,000 residents, lower than the rate of 562 per 100,000 in England, and higher than the average of 412 per 100,000 among its nearest neighbours. · York ranked 116th highest out of 149 upper tier local authorities (UTLAs) and unitary authorities (UAs) for new STI diagnoses excluding chlamydia among young people aged 15 to 24 years in 2020, with a rate of 378 per 100,000 residents aged 15 to 64, better than the rate of 619 per 100,000 for England. · The chlamydia detection rate per 100,000 young people aged 15 to 24 years in York was 1,107 in 2020, worse than the rate of 1,408 for England. · The rank for gonorrhoea diagnoses (a marker of high levels of risky sexual activity) in York was 117th highest (out of 149 UTLAs/UAs) in 2020. The rate per 100,000 was 40.3, better than the rate of 101 in England. · Among specialist sexual health service (SHS) patients from York who were eligible to be tested for HIV, the percentage tested in 2020 was 59.8%, better than the 46.0% in England. · The number of new HIV diagnoses among people aged 15 years and above in York was 6 in 2020. The prevalence of diagnosed HIV per 1,000 people aged 15 to 59 years in 2020 was 0.8, better than the rate of 2.3 in England. The rank for HIV prevalence in York was 140th highest (out of 148 UTLAs/UAs). · In York, in the three year period between 2018 - 20, the percentage of HIV diagnoses made at a late stage of infection (all individuals with CD4 count ≤350 cells/mm^3 within 3 months of diagnosis) was 53.3%, similar to 42.4% in England. · The total rate of long-acting reversible contraception (LARC) (excluding injections) prescribed in primary care, specialist and non-specialist SHS per 1,000 women aged 15 to 44 years living in York was 46.6 in 2020, higher than the rate of 34.6 per 1,000 women in England. The rate prescribed in primary care was 29.7 in York, higher than the rate of 21.1 in England. The rate prescribed in the other settings was 17.0 in York, higher than the rate of 13.4 in England. · The total abortion rate per 1,000 women aged 15 to 44 years in 2020 was 11.4 in York, lower than the England rate of 18.9 per 1,000. Of those women under 25 years who had an abortion in 2020, the proportion who had had a previous abortion was 19.1%, lower than 29.2% in England. · In 2019, the conception rate for under-18s in York was 16.4 per 1,000 girls aged 15 to 17 years, similar to the rate of 15.7 in England. · In 2019/20, the percentage of births to mothers under 18 years was 0.9%, similar to 0.7% in England overall.^[1]

Step 3 – Gaps in data and knowledge

3.1	What are the main gaps in information and understanding of the impact of your proposal?  Please indicate how any gaps will be dealt with.
Gaps in data or knowledge		Action to deal with this
What sexual health service can be commissioned within a financially restricted environment.		As part of the stakeholder and potential provider feedback questions have been asked about gaps in the current provision, what could be omitted from the National Sexual Health Service Specification and the impact of this. What potential providers see as the cost pressures and the impact of these on delivering the service, and any other challenges that we as commissioners may not be aware of. The feedback included a review of the on-line offer, the importance of a collaborative approach, a review of the KPI’s and suggestions on staff utilization, as support for reducing costs. The biggest cost pressures are staffing and challenges were noted as being succession planning, more understanding of services in the community and rethinking the digital offer. The majority who answered the question thought that a longer contract term would support cost effectiveness as it would support long term planning, development and motivation of staff and collaborative working.
Understanding of current need and analysis of the most recent data.		A comprehensive Sexual Health Needs Assessment has been completed. This is available to view here:xxxx

Step 4 – Analysing the impacts or effects.

4.1	Please consider what the evidence tells you about the likely impact (positive or negative) on people sharing a protected characteristic, i.e. how significant could the impacts be if we did not make any adjustments? Remember the duty is also positive – so please identify where the proposal offers opportunities to promote equality and/or foster good relations.
Equality Groups and Human Rights.		Key Findings/Impacts	Positive (+) Negative (-) Neutral (0)	High (H) Medium (M) Low (L)
Age		Likely to be positive as the service focuses on young people who are at risk from poor outcomes if their sexual health needs are not addressed	+	L
Disability		Likely to be positive as the service focuses ensuring that those with a disability are at risk from poor outcomes if their sexual health needs are not addressed	+	L
Gender		The service is open to all regardless of gender.	0	L
Gender Reassignment		The service is open to all regardless of gender reassignment.	0	L
Marriage and civil partnership		The service is open to all regardless of partnership status.	0	L
Pregnancy and maternity		The service is open to all women and those with a womb, but it is not a pregnancy or maternity service. Access to terminations is available via the service.	0	L
Race		The service is open to all regardless of race.	0	L
Religion and belief		The service is open to all regardless of religion and belief.	0	L
Sexual orientation		The specialist service makes specialist provision for all sexual orientations including Men who have sex with men, heterosexual, Homosexual and LGBTQ+ groups.	+	L
Other Socio-economic groups including :		Could other socio-economic groups be affected e.g. carers, ex-offenders, low incomes?
Carer		The service is open to all regardless of caring responsibilities and includes both virtual and f2f appointments and a wide variety of opening hours.	0	L
Low income groups		The service is free to all.	+	L
Veterans, Armed Forces Community		There has been no specific provision made for veterans and the armed forces but if this is highlighted as a need in the Needs assessment or via any of the consultations this would be addressed.  All service personnel can access any of the sexual health services.	0	L
Other
Impact on human rights:
List any human rights impacted.			0	L

Use the following guidance to inform your responses:

Indicate:

- Where you think that the proposal could have a POSITIVE impact on any of the equality groups like promoting equality and equal opportunities or improving relations within equality groups

- Where you think that the proposal could have a NEGATIVE impact on any of the equality groups, i.e. it could disadvantage them

- Where you think that this proposal has a NEUTRAL effect on any of the equality groups listed below i.e. it has no effect currently on equality groups.

It is important to remember that a proposal may be highly relevant to one aspect of equality and not relevant to another.

High impact (The proposal or process is very equality relevant)	There is significant potential for or evidence of adverse impact The proposal is institution wide or public facing The proposal has consequences for or affects significant numbers of people The proposal has the potential to make a significant contribution to promoting equality and the exercise of human rights.
Medium impact (The proposal or process is somewhat equality relevant)	There is some evidence to suggest potential for or evidence of adverse impact The proposal is institution wide or across services, but mainly internal The proposal has consequences for or affects some people The proposal has the potential to make a contribution to promoting equality and the exercise of human rights
Low impact (The proposal or process might be equality relevant)	There is little evidence to suggest that the proposal could result in adverse impact The proposal operates in a limited way The proposal has consequences for or affects few people The proposal may have the potential to contribute to promoting equality and the exercise of human rights

Step 5 - Mitigating adverse impacts and maximising positive impacts

5.1

Based on your findings, explain ways you plan to mitigate any unlawful prohibited conduct or unwanted adverse impact. Where positive impacts have been identified, what is been done to optimise opportunities to advance equality or foster good relations?

Inequalities exist across a range of dimensions, including ethnicity, gender, sexuality and having a disability. The underlying causes of these inequalities often cluster together, with people experiencing ‘multiple disadvantage’. The service specification and quarterly monitoring of the KPI’s ensures that the service is being accessed by those who experience poor sexual health and specific service provision is made for them, specially around gender, gender reassignment and sexuality. Working as a system wide approach requires all key stakeholders to work together to provide an efficient and effective service this include those who may be vulnerable to sexual exploitation due to their age, race or gender. Prior to the pandemic a Sexual Health Expert Advisory Partnership Group (SHEP) which included all key stakeholders met regularly to ensure that a system wide approach worked for all – it is anticipated that this will be re-established. A comprehensive Sexual Health Needs Assessment will also inform us of our populations needs. Together with the Service Specification and the engagement report it is the ambition of the Public health team that we will co-produce the final service specification indicating targeted areas for specialist work and where people can access sexual health advice information, treatment and management.

Step 6 – Recommendations and conclusions of the assessment

6.1	Having considered the potential or actual impacts you should be in a position to make an informed judgement on what should be done. In all cases, document your reasoning that justifies your decision. There are four main options you can take:
- No major change to the proposal – the EIA demonstrates the proposal is robust.  There is no                         potential for unlawful discrimination or adverse impact and you have taken all opportunities to    advance equality and foster good relations, subject to continuing monitor and review.
- Adjust the proposal – the EIA identifies potential problems or missed opportunities. This involves taking steps to remove any barriers, to better advance quality or to foster good relations. - Continue with the proposal (despite the potential for adverse impact) – you should clearly set out the justifications for doing this and how you believe the decision is compatible with our obligations under the duty - Stop and remove the proposal – if there are adverse effects that are not justified and cannot be mitigated, you should consider stopping the proposal altogether. If a proposal leads to unlawful discrimination it should be removed or changed. Important: If there are any adverse impacts you cannot mitigate, please provide a compelling reason in the justification column.
Option selected		Conclusions/justification
No major change to the proposal		The proposal forms part of the Specialist Sexual Health Service in York. This service is closely monitored at local authority level throughout the procurement process, the contract award process and the quarterly contract monitoring meetings which take place throughout the life of the contract. SHEP will also act as monitoring body and enable the positive relations across all stakeholders.

Step 7 – Summary of agreed actions resulting from the assessment

7.1	What action, by whom, will be undertaken as a result of the impact assessment.
Impact/issue		Action to be taken	Person responsible	Timescale
To complete the procurement process in accordance with CYC and legislative requirements.		Work with the successful provider to ensure, through contract monitoring, that there is equitable access.	Project steering group	Through out the procurement process and into award of the contract.

Step 8 - Monitor, review and improve

8. 1

How will the impact of your proposal be monitored and improved upon going forward?   Consider how will you identify the impact of activities on protected characteristics and other marginalised groups going forward? How will any learning and enhancements be capitalised on and embedded?

Any considerations identified via the Sexual Health Needs Assessment, the consultation and engagement phases of the procurement process will be reviewed and considered. Whilst writing the service specification the protected characteristics will be considered and consulted on.  Feedback for the engagement process will also be considered if any impacts on those with a protected characteristic are identified.

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[1] SPLASH Report