Securing the status and position
of health
244. Preventative measures and health promotion services
intuitively appear particularly well-suited to being driven by
primary care services, which are uniquely well-placed to tailor
preventative interventions closely to local health needs. However,
the recent reconfiguration of the NHS seems to have raised considerable
anxiety about whether, without a National Service Framework, PCTs
will retain the expertise and the motivation to give sufficient
priority and investment to preventative services in the area of
sexual health. We are concerned that many professionals argued
that the only way to get sexual health services improved was through
a National Service Framework. Given the public health and cost
benefit aspects of sexual health we would expect professionals,
trusts and PCTs to be able to provide adequate sexual health and
sexual health promotion facilities without further central directives.
We are having in this Report to recommend such further central
directives but feel that the Department should try to learn why
this group of patients has not been properly served by many local
NHS services.
245. Historically, responsibility for sexual health
promotion and preventative measures at a local level has rested
within the public health function of local health authorities,
and was usually funded through spending allocations ringfenced
for HIV prevention. The implementation of the Teenage Pregnancy
Strategy, led by local co-ordinators working across health and
social services, was also funded separately. Responsibility for
the commissioning and organisation of health promotion and public
health services has now shifted to PCTs, with the role of new
Strategic Health Authorities still little-understood. All PCTs
have a Director of Public Health, but not all have the resources
or expertise to establish dedicated sexual health promotion teams,
and with the transition from 95 Health Authorities to 303 PCTs,
there are considerable worries about dilution of expertise, as
voiced by Nick Springham, Health Improvement and Commissioning
Manager at Newcastle PCT:
Newcastle and North Tyneside are now two separate
PCT's, having been previously a single Health Authority District.
However, we have maintained one Health Promotion Department working
across the two PCT areas. This service is currently hosted by
Newcastle PCT. There was some discussion about splitting the service
in two, in order to better serve the individual PCT areas. However,
it was felt that if this were to happen, expertise developed across
Newcastle and North Tyneside would be lost to one or other of
the PCTs. Consequently, we have maintained the service across
the districts. This is working well, but I have concerns that
in some areas in the country a valuable and scare resource has
been watered down by the fragmentation of the old Health Authority-wide
Health Promotion services into separate PCTs.[218]
246. Eve Asante-Mensah, Chair of North Manchester
PCT, supported this concern:
As health authorities were dis-established a
lot of staff were displaced and did not come into PCTs and they
have left with an awful lot of experience and history about both
sexual health and HIV promotion and prevention particularly. As
a PCT, or Central Manchester Primary Care Trust, we have had quite
a deficit in terms of commissioning sexual health, we have not
had the experience and the expertise there.[219]
247. The main changes proposed to the delivery of
sexual health services set out in the Strategy consist
of their reorganisation into a three-level model. The only place
prevention services are explicitly mentioned in this model is
at level three (specialist service provision) which may include
outreach STI prevention services. Although contraceptive services
are available at both level one and level two, very little specific
guidance is given on providing services which help prevent as
well as deal with unintended pregnancies and STIs.
248. In terms of commissioning, again the Strategy
focuses almost exclusively on the commissioning of services to
detect and treat sexual health problems rather than to promote
sexual health and prevent problems arising in the first place.
Mr Springham argued:
It is most important that [the Commissioning
Toolkit] gives clear guidance on the importance of commissioning
sexual health promotion services. Pressure to achieve clinical
targets might result in sexual health promotion being marginalised.
Fighting for funds to work 'upstream' is difficult at the best
of times. The Toolkit needs to set out the importance of
this area of work, with clear standards. Many commission managers
do not necessarily have the background and experience in the field.
They are often more experienced in commissioning clinical services
rather than community support, education and health promotion
activities.[220]
249. The Commissioning Toolkit acknowledges
the unique difficulties faced by commissioners trying to balance
demands for diagnostic and treatment services against their own
responsibility for public health and preventative interventions,
and to this end promises a dedicated health promotion toolkit
"aiming to inform commissioners of a wide selection of comprehensive
evidence based health promotion methods and good practice."[221]
250. We welcome the Department of Health's efforts
to produce and disseminate a health promotion toolkit to support
commissioners. In relation to sexual health, this should specify
that all those providing services in any area of sexual health,
including GPs, GUM clinics, family planning clinics, and termination
of pregnancy services, should provide a full sexual health risk
assessment and sexual health promotion advice to all patients,
as clinically appropriate. We feel that health promotion services
in the field of sexual health are absolutely vital, but are also
one of the services most at risk of being marginalised and deprioritised,
given that demand for preventative services is never articulated
as vociferously by patients as demand for treatment, and that
targeted funding which has been available over the past decade
has been subsumed into mainstream allocations. There is a compelling
rationale for continued investment in health promotion and prevention.
If a healthier nation is to be created, sexual health promotion
needs the support and capacity to make a difference. Resources
need to be identified to maintain specialist health promotion
services, which provide training and advice to health professionals
and lead on community-based initiatives with target groups. PCTs
should be held to account for the commissioning of targeted HIV
prevention and sexual health promotion, both in terms of resource
input and effectiveness measures.
205 
