City of York Council

Equalities Impact Assessment

Who is submitting the proposal?

Directorate:		Public Health
Service Area:		Public Health – Sexual Health Commissioning
Name of the proposal :		Proposed changes to sexual health service provision
Lead officer:		Philippa Press
Date assessment completed:		1 May 2024
Names of those who contributed to the assessment :
Name	Job title		Organisation	Area of expertise
Philippa Press	Public Health Specialist		CYC	Public Health/Sexual Health Commissioning.

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.

Local Authorities have a statutory duty to provide Sexual health Services under the Health and Social Care Act 2012. These services are funded by the ringfenced Public Health Grant which is given to the LA directly from central government. The public health grant is 10% less in 2023/24 (real terms) that it was in 2013/14. This has had a significant effect on the resources which can be directed to the sexual health commissioned service. York and Scarborough NHS Hospital Trust has been the provider for the sexual health service over that last 10+ years and following a full tendering exercise where no other providers made a bid for the contract, the decision was taken this time to enter into a partnership agreement (called Section 75) with the trust for 10 years. The decision report Executive are receiving on the 13^th June 2024 requests an extension to the current contract while this S75 arrangement is finalised. The trust is very positive about this proposal and have agreed to work with CYC to ensure that a sexual health service can be provided within the budget envelope, but some key changes are required, and these will be the biggest changes since CYC first commissioned the service. This EIA discusses these changes and the impacts they may have and the mitigating measures we will put in place to reduce the negative impacts. Without prejudging the outcome of the consultation (and subject to contract), these changes could potentially include: · A reduction in the number of clinic hours the service is open for · A cap on activity relating to Preventx (online STI testing) · A cap on activity relating to LARC (Long-Acting Reversible Contraception)

1.2

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

The impacts of the changes proposed will be system wide. The provision of sexual health services for the population is not provided by one services alone, sexual health is provided, in different degrees by GP practitioners, Pharmacists, private providers, ICB and NHS England. The Specialist Sexual Health Service, the service that LA’s commission, provides all three tiers of service provision, from contraception to the treatment and management of Sexually Transmitted Infections (STI’s) and HIV. CYC has a statutory duty to provide Sexual Health Services as part of the Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013 (SI2013/351), part 2 Public Health Functions/6 Sexual Health Services.

1.3

Who are the stakeholders and what are their interests?

Service Users – The Specialist Sexual Health Service (SSHS) provides service users with open access, free confidential, non-judgemental services. Most of the adult population is sexually active and access to quality sexual health services improves the health and wellbeing of both individuals and populations. General Practitioners/Primary care GP’s – A large proportion of care is provided in general practice, often being the first access point for individuals with contraceptive concerns or needs. Those wanting to commence contraception, change contraception or get repeat prescriptions for contraception should contact their GP in the first instance. GPs also offer STI testing for some common STI’s including Chlamydia screening. This is not seen as “specialist” service or advice. Community Pharmacies - All community pharmacies are required to provide advice on sexual health, reproductive health and HIV services as part of their essential services, e.g. promotion of healthy lifestyles, providing opportunistic sexual health advice in public health campaigns, signposting people to other services. From April 2024 a new community pharmacy service was introduced, this enables community pharmacy teams to initiate oral Contraceptive for those who are not currently using contraception without the need for the individual to be seen by a GP and continue in the provision of oral contraception. This service will increase the provision of other sexual health services in future years. NHS including ICB and NHS England – ICBs have responsibility for the provision of termination providers for those who do not wish to continue with a pregnancy. This is a significant life experience and may have many impacts on the person terminating an unwanted pregnancy. To reduce unwanted pregnancy access to contraception services is crucial, especially for young women or those in vulnerable groups who may not have commenced contraception prior to their first sexual encounter. Local Authorities – for the commissioning of “Specialist” sexual health services which provides open access, free non-judgemental services this is important because good sexual health is not equally distributed within the population. Strong links exist between deprivation and STIs, teenage conceptions and abortions, with the highest burden borne by women, men who have sex with men (MSM), trans community, young people, and people from ethnic minority backgrounds. Similarly, HIV infection in the UK disproportionately affects gay, bisexual and other MSM, and black African populations. Some groups at higher risk of poor sexual health face stigma and discrimination, which can influence their ability to access services. The population of York experiences good sexual health with access to services when required. Sexually active people are aware of the options they have across the city to access sexual health care and know the most appropriate service for them to access. No-one should feel that due to sigma or discrimination that they cannot access the care they require in a way and place that puts them at ease. There are a range of options and ways for people to access this service – via telephone, on-line, face to face or virtual appointment. Reduce unwanted pregnancies and those attending for termination services. Increase the number of people diagnosed with HIV early so ensure a better prognosis. Reduce all STI’s by a better awareness of safe sex, condom usage and personal responsibility for our sexual health.

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.

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
The proposed changes have been suggested by the service to limit the impact on service users based on foot fall through the service.		The service provider has extensive knowledge in this area having provided the service for the last 10 years whilst it has been commissioned by the local authority and since inception as part of the NHS. Over time the service has proved to be innovative in its response to service changes and working in new ways, the service has already absorbed many pressures on budget and responded to national outbreaks when required, e.g. Mpox. The proposed changes to the service opening times are based on footfall and an analysis of the service usage. However it is noted that these changes will affect accessibility to the service and therefore the option available to service users need to be communicated widely. The proposed changes to the on-line STI testing offer via PreventiX is based on analysis of those people requesting tests and the frequency of requests. The quality impact assessment of those using this service concluded that it was used by those who are low risk, predominately for peace of mind. It would be better for these to come into service to have STI prevention explained, and appropriate contraception prescribed. The proposed change to cap numbers of LARC is that the increase of this is due to people not being able to access GP services.  LARC is one of the most expensive procedures and it is not a “specialist” service. Therefore, working with primary care partners to support their provision is a much more cost-effective implementation of this service that accessing a specialist service. Reviewing the on-line “virtual” appointment system is also required. Initially put in place during COVID it was originally thought that this would considerably reduce costs, however the opposite has been the case. The service has received a large number of requests for virtual appointments including those outside of the area.  As there is no mechanism to charge the resident authority for this, this has increased work and pressure on the service considerably. These extra costs include investment in IT, consultation room provision and if medication is required the service provides this and bares the cost of postage to the individual.
The service providers that these suggested changes have been developed in collaboration with internal partners including staff groups to minimise the impact on service users and staff.		Through consultation internally, the service has developed these proposals. Although it will require a vacancy freeze and a reduction in opening hours other options for service users are available and these have been considered including the sign posting to the new Pharmacy contraception service. Saturday morning opening will no longer be open to all but may develop into a specific clinic aimed at hard to reach clients.
A full consultation regarding all the changes will be completed following the final decisions.		As part of the new Section 75 agreement a full consultation which will include both service users, staff and key stakeholders will be carried out, the results of which will influence implementation.
Sexual Health Needs Assessment		Public health profiles - OHID (phe.org.uk) On the whole people in York experience good sexual health with some sectors of the population experiencing inequality. The Public Health Outcomes Framework – above shows that in most areas York is better than or equal to the national and regional average in STI diagnostic rates, accessing reliable contraception and the numbers attending for termination services. However rates of STI incidence have increased over the last couple of years, in line with national trends. However there is still work to be done to support young people in accessing chlamydia screening and increasing the detection of HIV, at an early stage, in at risk populations.

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
Actual impact of the changes on service users.		Consultation will take place prior to the changes taking place and also once they have been implemented feedback and review of the impact will continue.

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		Young people are likely to be most affected by limiting access to contraceptive services. However with the new community pharmacy offer this risk is mitigated to some extent as there are more opportunities to access contraception from the high street without the need to make an appointment. A local contraception, prevention campaign is planned to support people to find the correct services and ensuring that all ages know of the wider options for obtaining contraception.	Negative	H/M depending on the impact on service users. There is significant potential for adverse impact
Disability		As above. Community pharmacies are open 6 days a week and many are 100 hour pharmacies allowing access to contraception to be wider and therefore more accessible. The website holds specific information on sexual health for those with learning difficulties. YorSexualHealth - Learning Difficulties	Neutral (0)	L
Gender		More women than men use contraceptive services, and the campaign will target those groups who may be affected more. Information on pregnancy, terminations services, counselling, sexual assault and sex workers is available on the website with advice on where to get help and advice regardless of gender.	Negative	Medium
Gender Reassignment		Specialist clinics will be available for those who have specialist needs. This includes clinics specially for those who are transgender, Men who have sex with men and Sex Workers.	Neutral (0)	L
Marriage and civil partnership		No impacts	(0)	L
Pregnancy and maternity		Possibility of a rise in unplanned pregnancies and a knock on effect of a rise in demand for termination services.	(-)	L
Race		People from minority ethnic backgrounds are at higher risk to experiencing poor sexual health. Remote and on-line provision will still be available for those who are reluctant to access services in person.	negative	L
Religion and belief		No specific impacts	(0)	L
Sexual orientation		Communications with LGBTQ groups will be done via specialist services which the sexual health service work closely with.	(0)	L
Other Socio-economic groups including :		Could other socio-economic groups be affected e.g. carers, ex-offenders, low incomes?
Carer		No Specific impacts	(0)	L
Low income groups		No specific impacts	(0)	L
Veterans, Armed Forces Community		No Specific Impacts	(0)	L
Other		None
Impact on human rights:
List any human rights impacted.

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?

The Specialist sexual health service has long standing and secure relationship with those groups who may experience poor sexual health, we have worked with these groups over many years and we are confident that we can work together to mitigate any adverse impacts by offering on-line consultations, postal testing kits as well as a range of appointment types including booked appointment, walk-in and telephone/virtual. The planned campaign which will include communications team across the sector including CYC and the trust will ensure that the population are aware of where they can access sexual health advice, treatment and Care.  The service hosts a specialist contact number for those aged 17 and under, this is open to young people regardless of gender, disability or ethnicity. Young people can text anytime for support advice and treatment between 8.15 and 3.30 Monday to Friday.  This age group will be able to access emergency contraception, free condoms and pregnancy tests. The Specialist Clinical and Community Outreach Team (SCCOT) aims to meet the sexual health needs of young and/or vulnerable people, and to support colleagues and other professionals when providing sexual health care to these groups. Professionals working with vulnerable groups can refer into the service and it is available to any person over the age of 13. A free counselling service is available for those who are experiencing sexual health difficulties. Individuals can self-refer or be referred by a professional involved in their care. Up to 7 free appointments are offered and can be provided face to face, by video link or via telephone. We will work collaboratively with all groups to ensure that access to sexual health is still available and ensure that other services on offer are known. The campaign will support this knowledge and information specifically targeted at young people will be key to mitigate against possible negative impacts.

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		There are sexual health services available for the population of York. The specialist service should be seen as ‘specialist’ and those wishing to use oral contraception, gain a repeat prescription or ask general advice do not need to access a specialist service. We need to direct these requests to primary care services either in GP practices or community Pharmacists. The new contract will have the provision for Long Acting Contraception to be available in the community via GP’s, which we hope will make the process less time consuming. However, we are aware of how much pressure our primary care colleagues are under and the impact of this will need to be measured. Once the changes have been finally agreed a consultation will be completed with all stakeholders and service users and feedback will be taken into consideration, but services will need to fit the designated financial budget.

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
Reduction in clinical sessions available		Consultation on proposed changes. On-going consultation once changes have taken place.	Philippa Press (CYC) and YorSexualHealth	Part of Q1 of the extension period 1 July to 30 September
Ensuring that those most at risk of sexual health inequalities are not further impacted.		Consultation on proposed changes. On-going consultation once changes have taken place.	Philippa Press (CYC) and YorSexualHealth	Part of Q1 of the extension period 1 July to 30 September
Service to commence /continue with proposed changes to service provision		Reduction in clinic times, Cap on LARC provision, changes to PreventiX and the virtual appointment system.	YorSexualHealth Y&SHFT	Q2 of extension period 1 October to 30 December
Continue with new service provision and work towards finalising contractual requirements for S75		Initial review of new service structure, complete contractual requirements.	Y&SHFT, CYC, Joint Management Board. YorSexualHealth and Philippa Press	Q3 of extension period – 1^st January to 30 March 2025
S75 to be implemented and new service provision commence.		All contractual requirements completed	Y&SHFT, CYC, Joint Management Board. YorSexualHealth and Philippa Press	Q4/Q1 of the new contract – S75 to be in place by 1 April in-line with financial year.

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?

Monitoring a review of the service is on-going and monitoring meetings take place quarterly thought out the life of the contract. A sexual health network, which meets at least twice a year will also monitor impacts and includes organisations who work with marginalised groups. The sexual health network includes all organisations who work across the system to provide sexual health services including GP’s Community Pharmacy and rumination providers. Data from services will also be scrutinised regarding adverse impacts on the changes and solution to haw these may be mitigated against put in place.

Step 8 - Monitor, review and improve