Memorandum by the fpa (SH 26)
fpa is the only registered charity working to
improve the sexual health and reproductive rights of all people
throughout the UK. We run a comprehensive information service,
including a national Helpline, which responds to over 100,000
queries each year on a wide range of contraceptive and sexual
health issues. We also produce a variety of publications to support
professionals, and the public, and provide resources including
training courses for those involved in delivering sexual health
services. fpa provides a national voice on sexual health issues
and works with the public and professionals to ensure high quality
information and services are available to all who need them.
(i) The impact of the National Strategy for Sexual Health
and HIV on people's sexual health will not be seen for several
years. Therefore fpa believes it is crucial that that the messages
of the forthcoming national awareness campaign maintain high visibility
during its 10-year lifetime. In order to effect changes the campaign
must be reinforced by high profile national and local initiatives
and by accompanying modernisation and expansion of services.
(ii) fpa recommends that a national Chlamydia
screening programme should be a priority for the implementation
of the Strategy.
(iii) fpa believes that comprehensive data
collection on contraceptive provision in GP, family planning and
GUM clinics is required urgently to establish patterns and enable
action to be taken locally to redress imbalances.
(iv) fpa recommends that the legal framework
surrounding abortion is updated to provide women with abortion
on request in the first trimester, to enable nurses to undertake
abortions, and to allow abortions to be performed in a wider range
of premises, including family planning and community clinics.
(v) fpa believes that the Strategy should
be accompanied by a comprehensive staffing review and an audit
of staff education and training needs.
(vi) fpa believes that Government future
spending plans need to take account of the Strategy's 10-year
lifespan and to allocate sufficient funding accordingly. National
standards should be developed to regulate core aspects of sexual
health and facilitate care pathways.
1. Sexual health is key to our health and
wellbeing. Long term it impacts upon self-esteem, socio-economic
status and livelihood and is therefore influenced not only by
health issues, but also by policies relating to education, welfare,
and regeneration. This wider significance, and the major inequalities
in services, have led to sexual health occupying a major role
in public health strategies.
It was identified by the Government White Paper Saving Lives:
Our Healthier Nation
as "an important public health issue".
2. More recent preventative work has advocated
a highly medical model, focussing largely on reducing infections.
fpa believes that sexual health should be underpinned by a holistic
ethos, which positively promotes human sexuality and accepts sexual
activity as normal and life enhancing. A useful model is the Teenage
Pregnancy Strategy, which takes an integrated approach to the
contributing factors and examines the diverse range of influences
surrounding young people and sex.
3. If poor access to contraception and abortion
and increasing rates of sexually transmitted infections and HIV
are to be tackled, the Government needs to pursue a truly multilateral
approach and to foster an open and healthy environment for sex
and relationships to take place in. Sexual health needs to be
better integrated with teenage pregnancy programmes, community
development projects and within education and local government
to avoid services becoming isolated, and subjected to stigma and
4. fpa welcomed the announcement of the
first National Strategy for Sexual Health and HIV in 1999 and
contributed extensively to its development, as a member of the
Steering Group and a number of the working groups. fpa believes
that the Strategy contains some innovative ideas and laudable
principles but it also raises questions about the capacity of
services to effect wholesale change. It must therefore be accompanied
by significant reforms and sustained resources.
5. Nationally the Government must continue
to give sexual health political priority as a major public health
issue, by including it as a core part of its long term spending
plans and health improvement strategies. fpa believes that the
Strategy must be fortified by national standards encompassing
clinical audits and assessment, in order to enable everyone to
have access to the same high quality care and services.
6. Prevention (Chapter 3)
Prevention of ill health is one of the key factors
in improving sexual health. Not only is it cost effective,
but it also empowers users, a core principle of the NHS National
Plan, crucial for a service area which thrives on wellbeing not
The Strategy needs to tackle the information
deficit which exists in many areas of sexual health by supporting
the development of more relevant, up to date materials in accessible
formats, (ie large print, Braille, audio, video and in predominant
community languages) distributed through a variety of settings,
such as the workplace, benefits agencies, and community networks.
fpa is developing a range of leaflets on the
more common STIs, to compliment its range on contraception. This
will act as an invaluable resource for local providers and fill
the information gap, which currently exists.
6.2 Awareness Campaign
fpa welcomes the Strategy's commitment to a
national sexual health awareness campaign. To be effective this
must be sustained and include all facets of sexual health, particularly
those which are currently less comprehensively covered. For example,
recent fpa research showed that knowledge of contraception is
fpa is also concerned about the capacity of services to meet the
increased demand which the campaign will generate, therefore it
must be supplemented with detailed information resources, and
The Strategy's support for specialist information
services and Helplines, such as the one provided by fpa is welcome.
However to reach their full potential it is important that these
services are fully integrated with national Helplines, such as
NHS Direct vis-a"-vis information sharing and joint working.
7. Services (Chapter 4)
The term "postcode lottery" has become
an NHS cliché, however it is perhaps apt for sexual health
services. For example, provision of NHS funded abortions in England
varies from 46 per cent to 96 per cent
in health authorities. Inequalities in contraceptive services
are less well documented due to the lack of data. There is an
urgent need to ensure that comprehensive data collection is established
to enable the pattern of service changes, particularly around
GP contraceptive provision, to be monitored.
7.1 Service Model
Whilst the new tiered model outlined by the
Strategy is designed to promote clarity and consistency for users
and providers, the practical implementation presents problems.
The standards to be met at each level need to be comprehensively
outlined, as do the relationships between levels. For example,
STI testing for women is defined as a Level one service, and infections
management, a Level three service.
The issue of "core" level or "level
0" services creates a vacuum in the service model depicted
by the Strategy. Many services have not yet acquired the range
of services commensurate with Level one. The implementation must
support these services with adequate training and resources to
enable them to access the framework. fpa is producing a framework
for primary healthcare teams to set out the minimum standards
for a level one service to guide providers implementing the Strategy.
There are many areas of overlap between these
services (diagnosis, treatment, counselling, partner notification)
which blur the boundaries. Providers need to ensure that the levels
are properly integrated and that the specific staff training and
information support needs at each level (including "core"
level services) are met.
7.2 Chlamydia screening
The Strategy provides a much-needed commitment
to introduce chlamydia screening for high-risk groups from 2002.
However the growth in rates of infections
as well as the success of screening pilots
provides compelling evidence for a national screening programme
to be introduced urgently. It is important that the proper support
services, such as laboratories, are put in place to back up this
7.3 Contraceptive services
Contraceptive services are vital to sexual health
improvement, yet they remain fragmented and of variable quality.
GPs are not required to undergo mandatory training in this area,
but receive an item of service payment regardless of the quality
of service. Many do not offer the full range of 13 methods, and
some do not provide condoms. Family planning clinics, which do
provide a wider range, are like GUM clinics often difficult to
access in terms of location and opening times. fpa believes that
all sexual health services should be open access. Whilst the Strategy
commits to this principle, there is widespread misunderstanding
of what "open access" entails, and this needs to be
clarified prior to the implementation of the Strategy.
In order to effect changes in practice, primary
care teams must prioritise contraceptive services by improving
access to all methods, including emergency contraception. The
new commissioning arrangements should include all contraceptive
methods in their budgets and support the provision of local free
The new GP contract currently in negotiation,
provides a valuable opportunity to modernise the provision of
contraceptive services. This needs to highlight sexual health
as an important primary care priority, which GPs are well placed
Abortion services are already stretched with
women experiencing delays of up to six weeks.
The Strategy's inclusion of a headline target to provide women
with an abortion within three weeks of referral will only exacerbate
problems caused by an increasing national shortage of consultants,
access to GP referral, and inadequate information provision. Women's
access is also obstructed by the over-bureaucratic procedureservices
must be reformed to facilitate self-referral, and early abortions.
The modernisation of abortion services also
requires law reform. Women must be able to obtain abortion on
request within the first trimester. The greater involvement of
nurses, who are often highly experienced in abortion care, is
barred by the legal restriction that abortions can only be performed
by "registered medical practitioners." Increased support
for nurse-led services would enable nurses to utilise their skills
and provide women with quicker access to abortions.
The law also restricts abortions to hospitals
and medical premises. There is potential for more abortions to
be performed in less clinical settings such as community and family
planning clinics, and the home for one or more stages of medical
Women should also be offered greater control
over the method and timing of their abortion. There is potential
for greater knowledge and use of early surgical abortion, a less
intrusive procedure, which can be performed under local anaesthetic.
Medical abortion, which avoids the need for surgery, is only provided
by a third of services
thereby denying women access to this method.
7.5 Pregnancy testing
Pregnancy testing should be a vital part of
every Level one sexual health service but it is not generally
available through GPs. fpa believes its importance should be reflected
in the Strategy which must ensure that all primary care teams
offer free pregnancy testing and provide counselling for unplanned
8. Capacity (Chapter 6)
With sexual health services already stretched
to capacity in many areasie GUM, nursing and abortion,
the Strategy's anticipation of enhanced roles and additional workloads
for many professionals will be difficult to achieve. The restructuring
and reform of services to meet user expectations will be costly
for local commissioners, forced to prioritise according to local
8.1 Staff education and training
Clinical and non-clinical staff working in sexual
health often receive little or no training in many aspects of
sexuality, confidentiality, and communication skills. The Strategy
provides little practical support for providers and places enormous
additional training and updating demands on staff. The potential
contribution which nurses can make to service improvements (ie
prescribing and extended roles) is neglected.
8.2 Staff shortages
The deepening shortage of trained staff in many
areas of sexual health (ie GUM, family planning clinics and abortion
services) threatens the implementation of the Strategy. The recruitment
and retention problems must be tackled before staff can undertake
the extra challenges, which the Strategy presents.
The Strategy has initially allocated £47.5
million over the next two years "to facilitate baseline review
and data collection on sexual health"
prior to implementation. Given the magnitude of the reforms, overstretched
primary care services will require additional sustained resources
beyond 2004. The competing priorities which commissioners will
have to resource through their budgets threaten to marginalise
sexual health, as it is not perceived as an issue "for which
many Chief Executives will lose their jobs".
fpa is currently initiating a review into the
economics of sexual health services, with a view to publishing
an analysis of future resources required to modernise services.
It is hoped that this will be a useful tool for the Government
in formulating its allocation of long-term funds, and by local
commissioners charged with delivering service improvements over
a 10 year timescale.
1 Saving Lives: Our Healthier Nation, Department of
Health 1999; Tackling Health Inequalities, Department of Health,
Department of Health, 1999. Back
Maguire A, Hughes D, Economics of Family Planning, fpa, 1995. Back
fpa/NOP Research for Contraceptive Awareness Week 2002. Back
Health Statistics Quarterly, Summer 2001, Office for National
PHLS Diagnoses of selected sexually transmitted infections
(STIs) seen in genitourinary medicine clinics: England and Wales,
1995-2000, 2001. Back
Screening for genital chlamydial infection J Pimenta et al BMJ
9 September 200 v 321 pp 629-31. Back
Walsh J. Reviewing Contraceptive Services: research, findings
and framework. Health Education Authority, 1999. Back
British Pregnancy Advisory Service, 2001. Back
Royal College of Obstetricians and Gynaecologists. National Audit
of Induced Abortion 2000, September 2001. Back
Letter from Cathy Hamlyn, Head of Sexual Health and Substance
Misuse, to Health Authority Chief Executives, 29 November 2001. Back
Dr Caroline Mawer, Consultant in Public Health Medicine, Lambeth,
Southwark and Lewisham Health Authority; Presentation to National
Conference on the National Strategy for Sexual Health and HIV,
25 October 2001. Back