Select Committee on Health Third Report


231. There is no doubt that the prevention of sexual health problems, whether unintentional pregnancy or sexually transmitted infections, is a far preferable alternative to attempting to deal with their consequences. In addition to the short and long term physical and psychological morbidity (and mortality) associated with sexually transmitted infections and unintended pregnancies, the cost of treating these problems is very high, as the Strategy acknowledges:

    The prevention of unplanned pregnancy by NHS contraception services probably saves the NHS over £2.5 billion a year already. The average lifetime treatment costs for an HIV positive individual is calculated to be between £135,000 and £181,000 and the monetary value of preventing a single onward transmission is estimated to be somewhere between £0.5 and 1 million in terms of individual health benefits and treatment costs.[205]

232. Following its introductory aims and principles, the National Strategy for Sexual Health and HIV opens with a chapter devoted to 'Better Prevention'. Included under this heading are subsections on information for the public, HIV prevention, the role of mass media, the evidence base on prevention, and sexual health information for specific groups. Within this section, the Government pledges to:

  • Develop a new safer sex information campaign for the general population.
  • Ensure national helplines on HIV and safer sex are more responsive to people's information needs.
  • Use the work commissioned from the Health Development Agency to provide an evidence base for local HIV/STI prevention.
  • Exploit the wide range of media available for providing information on sexual health.
  • Set a target to reduce the number of newly acquired HIV infections.
  • Develop, with London health authorities and others, a strategic framework for HIV prevention for African communities.

233. The Government's proposed target is to reduce by 25% the number of newly acquired HIV infections and gonorrhoea infections by 2007. This is the only target included in the Strategy in respect of health promotion and prevention. Many of those giving evidence to us criticised the Strategy for presenting a 'medical model' of sexual health, overly focused on the detection and treatment of these problems rather than on their prevention and on more positive promotion of good sexual health. Nick Springham, Health Improvement and Commissioning Manager at Newcastle PCT, argued that "sex and sexuality need to be normalised. They are a fundamental part of what it is to be human. They are neither smutty nor dirty. They are not clinical issues but social issues."[206] Chris Ford, a North London GP, agreed:

    One of the slight problems with the Strategy was that it was very much pushing a medical model rather than, "Sex is fun, most of us have it, it is a very positive experience", and that should be pushed in terms of education around sex, how to have good sex, and sexual health for all. If you look at every other European country, sex is regarded as normal and is talked about in a healthy, open way.[207]

234. The Strategy's section on preventative services aims to cover a very broad and complex subject, but pays little attention to the practical difficulties of securing 'better prevention' in sexual health.

Getting the message across—a national information campaign

235. In the mid 1980s, the hard-hitting government 'Icebergs' campaign resulted in a leaflet on HIV and AIDS landing on the doormat of every household in the country. While our witnesses differed in their evaluations of the campaign's success, its reach and impact seem to have been large judging from the fact that it is clearly still well-remembered nearly twenty years on by those exposed to it. According to Professor Johnston, the campaign was a success, but its message has not been repeated, leading to an ebbing of public consciousness about these issues:

236. Data published by OFSTED support the theory of decreasing levels of awareness about HIV and AIDS amongst young people:

Changes in young people's perceptions of HIV and AIDS

Proportion of young people 'concerned' or 'very concerned' about HIV/ AIDS
(males aged 12-13)
Proportion of young people 'concerned' or 'very concerned' about HIV/ AIDS
(females aged 12-13)
Proportion of young people 'concerned' or 'very concerned' about HIV/ AIDS
(males aged 14-15)
Proportion of young people 'concerned' or 'very concerned' about HIV/ AIDS
(females aged 14-15)

Data source: Schools Health Education

Evidence-based practice

237. As Professor Johnson pointed out, we are living in a changing society, and "prevention messages need to be as up-to-date with the epidemiology as vaccines are up-to-date with the technology"[209]. The national information campaign promised by the Strategy came to fruition in Autumn 2002, with the launch of the 'Sex Lottery' campaign aimed primarily at the 18-30 age group. It is too early to attempt to evaluate the campaign's success, but responses from our witnesses were generally positive. The Health Development Agency (HDA) has a key role in reviewing evidence on sexual health promotion and prevention initiatives, and working with the Department to disseminate information to professionals, including examples of best practice, aims we support wholeheartedly. However, the HDA is amongst many to argue that "the strategy seems to place a greater emphasis on the absence of disease than on the promotion of well-being", and that "more attention needs to be paid to the role of sexual health promotion".[210] The HDA also recommended that, as part of the drive to reduce inequalities in sexual health, the Government needs to work with other departments to ensure consistent cross-government policy, in, for example, allowing access to condoms in prisons.[211]

238. The HDA's written evidence gave interesting interim positions on the three pieces of work they are currently carrying out regarding best practice in prevention of teenage pregnancy, STI prevention, and HIV prevention.[212] The HDA also identified considerable gaps in the sexual health promotion evidence base:

    The review-level evidence tells us nothing regarding the effectiveness of HIV prevention interventions targeting African communities or people with HIV, both priority populations for the UK. We also know very little about the impact of socio-political actions on the wider determinants of sexual risk behaviour - for instance about how attitudes towards gay men can affect their self-esteem and in turn their sexual behaviour; or how discrimination affects access to services … We also know very little about the relative impact of interventions according to socio-economic status, and how to reduce inequalities in sexual health.[213]

The wider impact of health promotion

239. As well as actually getting information across, experts argue that there is real value in national campaigns such as those detailed above in that they serve to 'legitimise' further efforts at a local level:

240. However, according to some of our witnesses, including Dr Sarah Randall, a family planning specialist from Portsmouth, there is still a long way to go in terms of normalising sex and sexual health:

    There was a campaign some time ago about trying to advertise emergency contraception, a concept where you might have little stickers in public conveniences for that. An awful lot of district councils said 'Oh, no, we cannot have that'. It is all back to this business that we cannot talk about sex openly, sex does not happen.[215]

241. As pointed out by the Sex Education Forum, information alone is not enough to change behaviour patterns: "The acquisition of knowledge about contraception is of limited or little use to a young person without education which helps them to develop the social and personal skills to obtain contraceptives, negotiate their use with a partner and use them properly."[216] In the view of Nick Springham, factual information needed to be linked to accessible services, and to be supported by practical help in accessing those services and resources, as well as help in improving confidence, assertiveness and negotiating skills:

    People also need the skills to be able to use that information and the understanding to be able to use that information. To just tell people, "Don't do this or do that or do the other" we know that is an important first step but not very effective. Most people in this country know that smoking is bad for you but we know there are a lot of people who continue to smoke. The skills around sexual health could be having the assertiveness to be able to make the choices that they want to make, whether that is saying "no" or whether that is saying "yes but" or "yes if".[217]

242. Many of our witnesses agreed that this sort of sexual health promotion should be an integral part of every child's school education, but although much good work has been set in train by the Government's Teenage Pregnancy Strategy, this subject is conspicuously absent from the Strategy. The subject of sex education for young people is discussed in more detail in the next section.

243. Sexual health promotion offers a long term solution to many of the sexual health problems which challenge society. It is clear from the evidence we have received that awareness-raising activity and information campaigns are important but they will not on their own bring about sustained behaviour change, particularly amongst those marginalised individuals, groups and communities most vulnerable to HIV and other sexually transmitted infections. We recognise the importance of targeted community-based initiatives, peer education programmes and outreach work and would urge PCTs to ensure these range of interventions are a central part of local HIV prevention and sexual health promotion programmes.

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:

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   Strategy, p 11  Back

206   Ev 135 Back

207   Q 554 Back

208   Q 268 Back

209   Q 313 Back

210   Ev 119 Back

211   Ibid. Back

212   Ev 120-22 Back

213   Ev 122 Back

214   Q 453 (Kaye Wellings) Back

215   Q157 Back

216   Ev 125 Back

217   Q 422  Back

218   Ev 133 Back

219   Q 406 Back

220   Ev 135  Back

221   Commissioning Toolkit, p 36 Back

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