Dear Colleague

Summary

1. The reduction of teenage pregnancy rates is one of the main objectives set out in the National Assembly’s Strategic framework for promoting sexual health in Wales. Young people’s use of contraception is often erratic and inconsistent and the majority visit advice and contraception services only after becoming sexually active.

Improving access to services by young people is central to the Assembly’s strategy.

2. Research with young people has identified the features of a trusted and accessible service. These include an age-specific focus, confidentiality, non-judgmental staff, accessible locations and opening hours, a friendly atmosphere and publicity in places where young people meet. To be effective, contraception and advice services for young people should be commissioned and provided against these criteria.

3. Part of the solution to Wales’s high rate of teenage pregnancy depends on the increasing involvement of boys and young men in decisions about relationships, contraception, sexual health and pregnancy. Although the number of men attending contraceptive clinics in Wales has more than quadrupled since 1975, they still form a tiny percentage of the overall attenders. This guidance also identifies ways in which services can be made more accessible and acceptable to boys and young men.

Action

4. All commissioners should follow this guidance when commissioning young people’s contraceptive and sexual health services from any provider in the statutory, primary care or voluntary sector.

6. Health Authorities should monitor performance of those delivering services against these criteria under their Health Improvement Programmes.

7. Services should be planned and evaluated in consultation with young people who reflect the diversity of the local community. Consultation should focus on service models, location, opening times and publicity. A number of different methods can be used to consult, e.g. user representation, focus groups, and questionnaires. Young people’s involvement should be ongoing.

Age specific service

8. Services should encourage access by younger teenagers by setting an upper age limit of 25 and encouraging older people to access other appropriate services and, in primary care, by running separate sessions for young people.

 Confidentiality

9. Confidentiality is of paramount importance to young people. Health professionals are bound by their professional codes of conduct which state that their duty of confidentiality to younger patients is the same as that owed to older patients.

10. All services providing contraceptive advice should have an explicit confidentiality policy which young people are made aware of.

11. If a request for contraception is made by a young person under 16, health professionals should work within the current legal framework and refer to Welsh Health Circular (86)17/WHC(FP)(86/10/WOC(86)15 Family Planning Services for Young People. If the young person is not competent to consent to treatment, and treatment is therefore not given, a request for confidentiality should be respected. There may be cases where a health professional believes that a young person is being exploited or abused or is in some danger of so being. In such a situation health professionals should act upon their concerns in line with local Area Child Protection Committee procedures. Commissioners of young person’s contraceptive and sexual health services should ensure that all staff are appropriately trained in child protection procedures.

Staff attitudes

12. Non-judgmental attitudes to sexual behaviour and reproductive choices are essential for effective communication with young people. This is an essential criterion in all staff recruitment, including receptionists.

13. All staff should have an individual on-going training plan within the organisation’s workforce plan. This should cover working with young people, including those at the lower end of the age spectrum, black and ethnic minorities; young men; and bisexual, gay and lesbian young people; young people with physical disability and young people with learning disabilities.

Atmosphere

14. Services should be in non-clinical and comfortable environments. Décor, including posters and magazines, should be designed with young people in mind, inclusive of young men’s culture, and reflect the diversity of the local community. The use of radio or TV can create a more informal atmosphere and help to protect the confidentiality of clients at reception.

Location

15. The location of services should offer young people easy access with sufficient anonymity. They should be:

• accessible from schools, colleges, and places where young people meet;
• on a regular bus/train route;
• accessible to young people with pushchairs and those with physical or learning disabilities.

16. Services in generic youth-friendly settings (and mobile services where appropriate) may be more acceptable to young people who are apprehensive about seeking contraceptive advice. Young people’s services that deal with other aspects of health e.g. sexually transmitted infections, menstruation, diet and acne, would be a valuable model, as might a service placed in a leisure setting.

Opening hours

17. Young people find it easiest to access advice when services are open every day. More restricted opening hours should:

• match young people’s availability and leisure time e.g. after school and weekends.
• take into account the timing and limitations of local public transport, particularly in rural areas;
• be responsive to when there is the highest need for emergency contraception, i.e. around weekends.

18. When services are closed, young people should be clearly signposted to the nearest source of advice, including specific information on access to hormonal emergency contraception through accident and emergency departments, and pharmacies.

Contraceptive and sexual health advice

19. To be effective, services should offer young people the time and support to make informed choices about their relationships and sexual health. This is particularly important for younger teenagers. Services should also ensure that young people understand how to use their chosen contraceptive method, together with condoms to protect against infection. Care should be taken to ensure young people understand the risks of using contraception erratically and how to access emergency contraception if contraception is not used. A minimum level of service should provide:

• staff trained in communicating with young people;
• condoms, hormonal contraception, including emergency contraception and injectable contraceptives;
• on-the-spot pregnancy testing and non-judgmental advice;
• where appropriate, referral to antenatal services;
• where appropriate, quick referral to NHS abortion services;
• wherever possible, chlamydia testing and treatment with partner notification undertaken in collaboration with local STI services;

20. Services should also offer verbal and written information about the following issues and support both young women and men in accessing local services providing:

• the full range of contraceptive methods;
• STI screening and treatment;
• Safer sex and relationships;
• non-judgmental pregnancy counselling;
• support services for teenage parents
• youth counselling.

21. Links should be established and maintained with other supportive services, such as youth agencies, including the voluntary sector, which provide advice and information on sexual health, so that they are able actively to facilitate onward referral when appropriate.

Pregnancy testing and pregnancy counselling

22. Apprehension about the disclosure of a pregnancy deters many teenagers from seeking early advice. As a result, a disproportionate number have abortions after the first trimester and attend late for antenatal care. Pregnancy testing, especially when the result is negative, provides an ideal opportunity for discussion about long term contraception choices and sexually transmitted infection prevention. Local services and publicity should encourage:

• early uptake of pregnancy testing, pregnancy counselling and referral to antenatal services when appropriate;
• quick referral to NHS funded abortion services, where abortion is the agreed course, in line with the Royal College of Obstetricians and Gynaecologists Evidence Based Guideline 7 (March 2000).

23. Practitioners with a conscientious objection should refer the patient to another doctor as soon as possible.

Publicity

24. Publicity materials should have resonance with the target group and highlight the words ‘free’ and ‘confidential’. The term ‘family planning’ should be avoided. Information about services, including the address, telephone number and opening times, should be provided to:

• schools, so that young people have access to, and information about contraceptive information, advice and services;
• further education and higher education institutions, community centres, leisure centres, bars, clubs and cinemas and other places where young people meet;
• local phone directories Thomsons and Yellow Pages, listed and cross referenced under ‘contraception’, ‘pregnancy testing’ and ‘sexual health’;
• all professionals working with young people and all other sexual health service providers.

25. Consideration needs to be given to proactively publicising services amongst the " hard to reach" groups of young people who may not attend school and do not engage with mainstream services. Local outreach youth workers, drug and alcohol workers, leaving care teams and advocacy services are examples of potential publicity channels.

Reaching boys and young men

26. Boys and young men often access services in ways that make effective engagement difficult. Nervousness and apprehension may be displayed in extreme reticence or in noise and bravado. This often makes staff view boys and young men as problematic which further reinforces their feelings that they are not welcome. The challenge for services is to find ways of engaging boys and young men so they feel sufficiently at ease to ask for the sexual health information and support they need. This might be done in a variety of ways.

• Minimising the registration protocol at the first visit. The first contact boys and young men make with a service can determine whether or not they return. The aim of the service should be to demonstrate that the service is safe for them to use. This might simply involve reassurance about confidentiality and telling them what information and services are available. They can then choose to talk further or to make another visit.

• Including the opportunity for one to one consultations as a routine part of the first visit. Much of the bravado falls away when boys and young men leave the pressures of their peer group. Being seen individually provides a confidential safe space to ask for what they need.

• Through consultations with girlfriends. Many young men accompany their partners to services. Staff who are confident in working with boys and young men can both involve them in discussions about contraception and find out whether they have specific questions about their own sexual health.

• Opportunistically, in primary care. On average boys access general practice twice a year for general health problems. This provides an opportunity for GPs or practice nurses to raise sexual health issues, offer reassurance about confidentiality and ensure boys and young men know where they can get advice and free condoms if and when they need them.

• By being able to provide appropriate information and advice on sexual health to young gay men.

27. The provision of free condoms is a major factor in attracting boys and young men to visit services. Different models of condom distribution have been developed locally but wherever condoms are provided there must be a clear policy for staff to follow. This provides the necessary management support for workers to deliver the service with confidence. This is particularly important in detached work in non-clinic settings and in work with younger boys.

28. Where free supplies are limited, services might provide an initial ‘starter pack’ of free condoms with education about how to use them correctly and information about emergency contraception should any problems occur. This might be particularly appropriate in general practice.

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