Right to choose

Rosie Mundt LeachWith family planning a sensitive and controversial subject, the sexual health needs of service users can be overlooked. Rosie Mundt-Leach tells DDN how a south London drug service has teamed up with commissioners and sexual health experts to offer open in-house clinics, with promising results

The pain of a pregnancy ending in a baby being removed into care immediately after birth is one of the most distressing experiences known to those involved in drug and alcohol treatment – yet it is all too familiar to drug and alcohol service users, their families and clinical staff. When it has happened once to an individual woman, it is more likely to happen again when another pregnancy occurs – often very soon after the first removal, and with no time to achieve stability before the mother is once again traumatised and demoralised even further.

The Hidden harm report (2003) recommended that contraceptive services should be provided through specialist drug agencies, but this has not happened in practice. Staff at South London and Maudsley NHS Trust (SLaM) addiction services approached colleagues in Guy’s and St Thomas’ NHS Foundation Trust (GSTT) community sexual health and asked for help to make contraception available to women with substance problems, while enabling them to retain their fertility and have the best possible chance of successfully conceiving and keeping their children when their recovery was secure. Two years later, we can evaluate the success of this joint working and look at further ways to help marginalised people gain access to sexual health services.

An audit in 2012 showed high levels of unmet need for contraception among women using SLaM addiction services. Sexually active women said they were worried about pregnancy, but were not using contraception. In April 2013, using one-off start-up funding provided by Southwark drug and alcohol commissioners, an agreement was reached that the consultant in community sexual health and HIV from GSTT together with our already established BBV nurse would start providing health care on drug service premises. 

Due to administrative delays, direct work with patients did not start until June. While waiting, links were made with a brand new, fully equipped, sexual health clinic just ten minutes’ walk from the Southwark community drug and alcohol team (SCDAT) base.  Staff at SCDAT visited this clinic and actively informed service users about it. Privileged access was provided so there would be no need for appointments and no queuing, but even so, only one person per month used this opportunity, demonstrating that an in-house service might be more effective.

In June 2013, the in-house clinic opened for four hours per week, backed up by some additional visits outside clinic hours when SCDAT service users asked to see the sexual health consultant. There have now been 52 clinic sessions and a total of 184 consultations; 43 individual men and 74 women have received services. Some people have come with a partner (both different sex and same sex), many have come on their own, and often introductions have been made by their key worker.

A total of 74 sexually transmitted infection (STI) screens have been carried out and 67 BBV (including HIV) screens. Treatments for STIs have been started and/or completed and the risk of transmission has been eliminated. Twenty-five women have received (often long overdue) cervical smears. Investigations of incontinence, sexual dysfunction, and prostate cancer have been carried out, and concerns about sexual abuse, sexual assault, intimate partner violence, and infertility have been raised and suitable referrals made.

Long acting reversible contraception (LARC) gives drug and alcohol dependent women the opportunity to delay pregnancy while establishing their recovery. If the woman chooses to stop the method it is removed and fertility is restored – she doesn’t have to give a reason for asking for removal, this is done immediately, at any time, on request without question. The hormonal contraceptive Depo-Provera (depot medroxyprogesterone acetate, or DMPA) is an exception to this, as the 12-week injection itself cannot be reversed and there can be a delay before fertility resumes once the method is stopped; this is always explained before a woman chooses this method. None of the LARC methods prevent STI transmission, and none are prone to failure due to user error as is the case with oral contraceptive pills and condoms.

Data shows that individuals using the clinic represent service users with the most complex needs and the most severe poly-drug and alcohol dependency. This demonstrates that the clinic is meeting the needs of drug and alcohol users who would not otherwise attend any sexual health service, and is not just being used as an alternative to mainstream services by people who have milder addiction problems. Women were more heavily represented in the group using the service, although they only make up one third of the CDAT population, so we are satisfied that they are gaining more than fair access to the provision that they need.

The average number of consultations per clinic session is 3.5, leaving room for more, and we have provided contingency management to increase uptake. Small value shopping vouchers of £2 have been offered to people for having an STI screen and £5 for those having a LARC method or a cervical screen. This gained ethical approval and is in line with local policy for incentivising BBV screening and vaccination. The sums were deliberately kept small in order not to bring undue influence to bear on decision making.

We believe that the most important factor influencing attendance at the clinic is accessibility and also providing additional training to drug service key workers to enable them to become more confident in recognising unmet sexual/reproductive health needs and to talk in more depth about options.

We opened a subsidiary clinic in another smaller agency run by Blenheim that is also part of Southwark Treatment and Recovery Partnership. However, we found that the uptake was low, so this was suspended. All service users from any drug/alcohol treatment agency in the borough are invited to use the clinic at SCDAT, so nobody is excluded.

Both sides of the professional partnership have learned valuable lessons from one another and from the service users’ reactions to the new service. The addiction staff group was originally focused on contraception, but soon realised the huge benefits to patients of a full sexual and reproductive health service provision, including STI screening and treatment, initial management of sexual dysfunction, genital skin problems, cervical screening, initial management for fertility and menstrual and bladder problems. 

The sexual health staff found how closely addiction staff work with service users and how fundamental the key worker relationship is to enabling people to take up healthcare. Simply placing a sexual health clinic in the drug service would not have worked – the partnership between staff, service users, reception staff and peer mentors was vital to the project being accepted and used. The most important factors in overcoming reluctance to attend the clinic were the expertise of the staff and word of mouth that the treatment was quick, painless and empathetic.

Working with drug or alcohol dependence provides technical challenges for clinical staff, which this approach has succeeded in addressing. Firstly, our BBV nurse who supports the clinic has a local reputation for expert blood taking skills, so blood tests are done quickly even for people with very poor veins, and everyone knows they have nothing to fear. This facilitates STI screens and liver tests. 

Secondly, liver damage is a relative risk factor that has to be assessed when providing most prescribed contraceptive methods. Having a consultant-level clinician available to assess that risk is an efficient way of safely establishing the options that are available to the woman concerned and confidently helping her to decide how she wishes to proceed.

The host drug/alcohol service needs a relatively high level of daily visits to make adequate use of the time of the specialist service providers. Even though numbers seen in our service have been relatively low each week compared to mainstream sexual health services, the positive impact is disproportionately high. Undetected and untreated STIs, incontinence suffered in silence, hidden sexual dysfunction and worries about cancer are bad enough, but the human and financial costs of an unplanned pregnancy where a baby will be placed in care (care proceedings alone cost £25,000 per child) are devastating. We believe that we have found a way of addressing these issues by providing an in-house reproductive and sexual health clinic.

We were delighted that the clinic won the 2013 David Bromham Memorial Award from the Royal College of Obstetricians and Gynaecologists’ faculty of sexual and reproductive health in recognition of innovative sexual health practice. We are now looking at developing our approach in other drug services and we are also considering the implications of what we have learned for people with mental health problems and for other socially disadvantaged people who may be at risk of exploitation or unplanned pregnancy with a high risk of repeat removals of children into the social care system.

Rosie Mundt-Leach is head of nursing for the Addictions Clinical Academic Group, South London and Maudsley NHS Foundation Trust.

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