Select Committee on Health Minutes of Evidence

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[1]. It was identified by the Government White Paper Saving Lives: Our Healthier Nation[2] 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 downgrading.

  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[3], but it also empowers users, a core principle of the NHS National Plan, crucial for a service area which thrives on wellbeing not sickness.

6.1  Information

  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 extremely variable[4]. 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 local reforms.

6.3  Helplines

  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[5] 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[6] as well as the success of screening pilots[7] 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 intervention.

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[8], 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 condom schemes.

  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 to support.

7.4  Abortion

  Abortion services are already stretched with women experiencing delays of up to six weeks[9]. 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 procedure—services 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 abortion.

  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[10] 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 pregnancies.

8.   Capacity (Chapter 6)

  With sexual health services already stretched to capacity in many areas—ie 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 needs.

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.

8.3  Resources

  The Strategy has initially allocated £47.5 million over the next two years "to facilitate baseline review and data collection on sexual health"[11] 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"[12].

  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, 2001. Back

2   Department of Health, 1999. Back

3   Maguire A, Hughes D, Economics of Family Planning, fpa, 1995. Back

4   fpa/NOP Research for Contraceptive Awareness Week 2002. Back

5   Health Statistics Quarterly, Summer 2001, Office for National Statistics. Back

6   PHLS Diagnoses of selected sexually transmitted infections (STIs) seen in genitourinary medicine clinics: England and Wales, 1995-2000, 2001. Back

7   Screening for genital chlamydial infection J Pimenta et al BMJ 9 September 200 v 321 pp 629-31. Back

8   Walsh J. Reviewing Contraceptive Services: research, findings and framework. Health Education Authority, 1999. Back

9   British Pregnancy Advisory Service, 2001. Back

10   Royal College of Obstetricians and Gynaecologists. National Audit of Induced Abortion 2000, September 2001. Back

11   Letter from Cathy Hamlyn, Head of Sexual Health and Substance Misuse, to Health Authority Chief Executives, 29 November 2001. Back

12   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

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 19 August 2002