The NHS number has been included in the Clinical Care Record of the CDSSH to allow patient records to be linked within and between clinical services in order to directly improve patient management and care. For example, it will allow clinicians to evaluate quickly whether the patient’s previous or ongoing conditions or treatments at other services may impact on management of new episodes requiring care, or whether the patient is due to be offered a particular service, such as Chlamydia screening.The difficulty of collecting the NHS number by certain providers is recognised and will be addressed as part of the wider National Programme for IT (NPfIT). Clinic specific patients codes may need to be used in the interim. It is intended that patients will have the ability to keep aspects of their care record confidential, and can choose which health providers can access their information.

Only the encrypted NHS number will be transmitted to secondary users. Encryption will, however, allow unique numbers to be linked. Linkage is important to de-duplicate patient records in order to:

Date of registration

The date on which patient registered with the clinic or practice.

The date when a patient registers with a given service is necessary for administrative purposes. This is the point at which demographic information about the patient is recorded.

Many items of service should be offered routinely to patients at registration. For example, the National Strategy for Sexual Health and HIV aims to have all homosexual and bisexual men offered hepatitis B immunisation at their first visit at a GUM clinic. Date of registration can therefore be used to monitor and assess trends in specific items of service provision over time.

When analysing data from general practice settings, ‘Date of registration’ may also be used along with ‘Date of transfer out’ to calculate person years at risk of the total registered patient population, to estimate the incidence of a given outcome within the registered patient population.

Date of transfer out

This applies to general practices only and is the date when the patient leaves the practice.

The date when a patient transfers out and is no longer registered with a practice is necessary for administrative purposes within the practice. For example, patients who are no longer registered with a practice would no longer be re-called for cervical cytology screening.

When analysing data from general practice settings, ‘Date of transfer out’ may also be used along with ‘Date of registration’ to calculate person years at risk of the total registered patient population, to estimate the incidence of a given outcome within the registered patient population.

Gender

A self-defined classification of the sex of a person.

Patient gender is relevant to all aspects of sexual health service provision. Most aspects of service provision, patient management practices and sexual health outcomes are gender specific (e.g. contraceptive provision, cervical cytology screening, STI sequelae, sexual dysfunction). The majority of clinical audits, assessments of service provision and of public health burden would therefore require data to be gender specific.

Date of birth

The date on which a person was born or is officially deemed to have been born.

Patient date of birth is required by health providers to help establish patient identity when linking patient records, especially when patient NHS number is not available. Certain aspects of sexual health service provision are triggered when patients reach a certain age. For example, Chlamydia screening should be initiated at age 16 until age 25 and cervical cytology screening should be initiated at age 25 until age 65.

Only year of birth will be transmitted to secondary users. Year of birth will be used to estimate patient age in order to (1) assess whether service provision has been appropriately implemented and targeted according to national guidelines, (2) commission and plan appropriate services, and (3) assess which population sub-groups have greatest need/poor sexual health.

Postcode of residence

The code allocated by the Post Office to identify a group of postal delivery points.

Patient postcode of residence is required by health providers to help establish patient identity when linking patient records, especially when patient NHS number is not available. For the majority of services, postcode of residence would be collected alongside patient contact information to facilitate follow-up or re-call, for example, when giving diagnostic test results or when inviting a patient for cervical cytology.

Patient postcode is also required by clinic/practice software to generate PCT of residence.

Patient postcode will not be transmitted to secondary users.

PCT of residence

Primary Care Trust (PCT) is a legal entity, set up by order of the Secretary of State. It is a free-standing NHS body, performance managed by a Strategic Health Authority.

Local commissioners and planners of sexual health services need to know whether there is adequate service provision for their residents. Patients may cross PCT boundaries to access healthcare when local services are inadequate and this in turn may seriously impact upon service provision in neighbouring PCTs. Understanding how patients travel for their healthcare is essential when planning and commissioning new services.

Area of residence is also a strong predictor of sexual ill health and inequalities in healthcare provision. For example, delays in access to termination of pregnancy services and rates of some STIs are strongly influenced by area of residence. The allocation of funding to develop local services and targeted prevention activities therefore requires the collation of information on sexual health indicators by area of residence.

Ethnicity

A self-defined classification of groups of people having a common national or cultural tradition.

There is growing evidence that access to healthcare and health outcomes, including sexual health outcomes, vary considerably by ethnic group. For example, in some areas rates of gonorrhoea are 10 times higher in black Caribbeans compared with whites. Data on patient ethnicity is therefore vital in order to (1) assess which population sub-groups have greatest need/poor sexual health, (2) monitor inequalities in access to and delivery of sexual health care, (3) commission and plan appropriate services, (4) develop targeted and culturally appropriate health promotion campaigns, and (5) assess the effectiveness of local and national health prevention messages and public health policy.

Country of birth

The country in which the patient was born as defined by current political boundaries.

Certain immigrant populations are at high risk of poor sexual health outcomes, such as HIV infection. Clinicians must be able to assess a patient’s risk of such outcomes if they are to deliver appropriate and adequate health care.

As with ethnicity, data on country of birth is vital for commissioners and other healthcare professionals in order to (1) assess whether there are specific immigrant populations with greater need/poor sexual health, (2) monitor inequalities in access to and delivery of sexual health care, (3) commission and plan appropriate services, (4) develop targeted and culturally appropriate health promotion campaigns, and (5) assess the effectiveness of local and national health prevention messages and public health policy.

Sexual orientation

A self-defined classification of a person's sexual interest toward members of the same, opposite, or both sexes.

A patient’s sexual orientation is central to the appropriate management of their needs by sexual health providers. Sexual ill health outcomes vary considerably by sexual orientation and patients must be offered relevant services. For example, men who have sex with men are at much greater risk if HIV and hepatitis B infection and should routinely be offered an HIV test and hepatitis B vaccine when first attending a service, and should subsequently be offered an HIV test at each subsequent new attendance.

Data on sexual orientation is vital for commissioners and other healthcare professionals in order to (1) commission and plan appropriate services, (2) develop targeted and appropriate health promotion campaigns, and (3) assess the effectiveness of local and national health prevention messages and public health policy.

Attendance Information

Date of attendance

The date the patient attended or telephoned the clinic for a healthcare consultation. This includes telephone contact to receive a test result, organise prescriptions etc. but excludes contacts to make appointments or for other administrative reasons.

The date when a patient contacts or attends a given service for a healthcare consultation is necessary for all aspects of clinic administration and patient management.

First contact with service for this episode

This indicates whether a patient is making a first or follow-up attendance (face to face or by telephone).

New face to face attendances must be distinguishable from follow-up attendances because: (1) Many items of service should be offered routinely to patients at each new attendance (i.e. at the start of each new episode). For example, all homosexual and bisexual men should be offered an HIV test at each new attendance at a GUM clinic. First contact information can therefore be used to audit HIV test uptake by new attendees. (2) A sexual history should be taken at each new attendance. (3) Payments to service providers by hospital trusts or PCTs (‘Payment by Results’) will differ for new and follow-up patient attendances.

No. of days since 1^st attempt to make appointment/be seen

The first attempt by the patient to make an appointment with the clinic, expressed as the time in days before the first attendance.

The number of days since a patient’s first attempt to make appointment with, or be seen by, a service provider is used along with the first appointment date offered and the date of attendance to estimate waiting times for this service provider. This would be collected by all service providers within a PCT allowing average waiting times for sexual health services within a PCT to be estimated.

First appointment date offered

The first date on which the clinic offered to see the patient.

The first appointment date offered is used along with the number of days since a patient’s first attempt to make appointment with, or be seen by, a service provider, and the date of attendance, to estimate waiting times for this service provider. This would be collected by all service providers within a PCT allowing average waiting times for sexual health services within a PCT to be estimated. This date is to be collected in addition to the actual date of first attendance in recognition of the fact patients may choose not to take up the first offered appointment

Event Information (Item of service provided/reason for attendance)

Date of event

The date on which an item of service (event) was carried out.

The date when an item of service is provided is necessary for clinic administration and patient management. It may differ form the date of attendance. For example, the date of event may reflect the date a diagnosis was made by the laboratory some days after the patient attended the service. Such information may be useful for auditing turnaround of laboratory services.

Event type

This identifies the type of interaction the patient has with the health service, or the type of activity undertaken in relation to the patient within the health service.

All audits of patient management and clinical practice, and all monitoring of healthcare outcomes, will require information on the type of service provided i.e. whether an investigation, diagnosis, treatment etc. This needs to be qualified by an event type, as some medical terms can refer to more than one type of event. For example, colposcopy may refer to an investigation or to treatment.

Event code

The medical or therapy code referring to the terms that describe the service provided.

The medical and therapy codes map to medical and therapy terms describing the item of service provided to the patient. Existing medical and therapy terminologies include Read, KC60, and KT31. These terminologies can be mapped to SNOMED-CT, which will be adopted across the NHS as part of NPfIT. To view the range of terms currently defined under Event Code click here.

Sexual History Information

Detailed sexual history taking is a vital component of all sexual health service provision. Clinicians should use sexual history information to assess a patient’s risk of STI (including HIV), unwanted pregnancy, or other sexual health problems, to inform decisions on which screening tests, investigations, or treatments, if any, are appropriate, and whether partners need to be notified and treated.

Ongoing, comprehensive data on sexual risk factors and behaviours are important for developing relevant and targeted interventions and health promotion campaigns. They also facilitate detailed epidemiological analyses that improve understanding of infection transmission dynamics, ‘core groups’ and associations between cultural background, behaviour and sexual ill health.

The rationale for the inclusion of each specific sexual history item is given below.

History of previous STI

This indicates whether the patient has a history of any previous sexually transmitted infections (STIs).

There is strong evidence that patients with a history of STI are at particular risk of subsequent infections and complications such as pelvic inflammatory disease and infertility.

New sexual partner in the last 3 months?

This determines whether a patient has had at least one new sexual partner in the last 3 months.

Patients who have recently acquired a new sexual partner may be in need of appropriate fertility control and are at greater risk of STI, especially Chlamydia, than those who have not.

If yes, new partner male or female?

The gender of the most recent, new sexual partner in the last 3 months.

The gender of a patient’s partner/s is vital for determining a patient’s risk of certain STIs and pregnancy, and cannot always be assumed from information the patient provides on their sexual orientation. For example, a man may identify himself as heterosexual but be sexually active with other men.

Two or more sexual partners in the last year?

This indicates whether the patient had two or more sexual partners in the last 12 months.

There is strong evidence that the risk of poor sexual health increases with the number of sexual partners. This question will help facilitate questioning around specific partners who may need to be notified for epidemiological treatment of STIs and would give clinicians the opportunity to counsel patients on safer sexual behaviour.

Number of male partners in the last 3 months?

Questions 19a-d determine the number and gender of sexual partners the patient has had in the last 3 or 12 months.

Some patients may report large numbers of sexual partners and are at particular risk of STI and HIV infection. Specific questions on the number and gender of sexual partners would only be asked by those delivering specialist sexual health services, such as at GUM clinics. Patients would be questioned on numbers of partners over a 3 or 12-month period, as deemed clinically appropriate. For example, patients reporting more than 10 partners within a 3-month period would not be asked further questions on partners over the 12-month period. These questions will help facilitate questioning around specific partners who may need to be notified for further management, and would give clinicians the opportunity to counsel patients on safer sexual behaviour.

Number of female partners in the last 3 months?

Number of male partners in the last 12 months?

Number of female partners in the last 12 months?

Sex abroad (not with a UK resident) in the last year?

This question determines whether the patient has had sexual intercourse with a non-UK resident in the previous 12 months.

Infections like syphilis and HIV are more common in certain countries outside of the UK, as is the prevalence of antimicrobial resistance among some causes of STI, such as in parts of Africa, the Far East and Eastern Europe, and those who have unprotected sex with someone from a high prevalence area are likely to be at greater risk of infection or more likely to require treatment with antimicrobials used for resistant infections.. This question will help the clinician determine whether further probing on the patient’s risk of exposure is necessary. Such information is also of use in determining whether infections are endemic to the UK or are imported, and how this changes over time.

Number and outcome of previous pregnancies?

The number of the patient’s previous pregnancies and their outcome.

Pregnancy history is an important determinant of a woman’s sexual health and well-being. Some patients reporting unplanned pregnancies and previously induced abortions may be in particular need of fertility control care and advice, and these questions will help the clinician gain a good assessment of the patient’s risk of future unplanned pregnancy. A history of non-induced abortions in those wishing to become pregnant may indicate the need for specialist fertility treatment.

At risk of unplanned pregnancy?

The clinician’s judgement on whether the patient is placing herself at risk of un-planned pregnancy.

All women at risk of an unplanned pregnancy should be given counselling and offered appropriate fertility control. Women at risk of unplanned pregnancy are also likely to be at risk of acquiring STIs.