Select Committee on Health Third Report


The cultural context of changing sexual behaviour

313. Dr Kate Guthrie, a family planning specialist, spoke for many of our witnesses with her stark statement that "the British are very bad at sex altogether".[273] According to Dr Guthrie, sexual health has become "a medical problem, but it is only medical because we mop up. It is really a cultural and attitudinal problem." Cathy Hamlyn, head of the sexual health unit at the Department of Health, clearly supported this view: "We are stiff upper lipped. We can't talk easily about sex in this country. But we are also a little coy and giggly about sex. I sometimes call this the Benny Hill culture - a culture where we are not very open about things."[274]

314. As constituency MPs, the information we receive in our surgeries and in letters from our constituents can provide a useful barometer of key problems with our local health services. However, the fact that despite sexual health services reaching crisis point in some areas sexual health problems are rarely, if ever, brought to our attention by individuals illustrates the culture of embarrassment and secrecy that still surround sexual health in this country.

315. Attempting to change cultures and attitudes that are deeply entrenched in the national psyche may seem a fruitless aim. However, we were encouraged to hear the view of Gill Frances, Policy Director at the National Children's Bureau, who argued that the Netherlands is now starting to reap the benefits of sexual health interventions put in place thirty years ago, as the young people of the early 1970s have now had their own children and are passing on a new set of values, where sex and sexual health are openly discussed, to today's young people.

316. Responsibility for influencing societal attitudes goes well beyond the sphere of Government. In this context, we note that the BMA in their oral evidence said that their "main area of concern" was the "lack of significant representation of sexually transmitted infections as a significant health problem in the media". They called on the Broadcasting Standards Commission to survey this area and make representations to broadcasters to assist here.[275] Nick Partridge, for the Terrence Higgins Trust, pointed out it was wrong to lump the media together in describing its coverage of HIV/AIDS. He paid tribute, for example, to the educative impact of the Mark Fowler story line in Eastenders, on which the Trust had been consulted, and to the role of the Deirdre column in The Sun. But he also noted the confusion and mixed messages prevalent in the media, particularly denigrating "knee-jerk reactions" to stories relating to sex education in schools.[276] We ourselves witnessed at close hand the capacity of the British media to trivialise and smirk at issues relating to sex education: it struck us as depressing and distasteful that, when we took evidence from young people aged 15 to 21, who showed real courage in coming before a Parliamentary Committee and gave thought-provoking and well-articulated evidence, this was largely reported by newspapers' diary columnists. Predictably enough, their aim was to ridicule the evidence we received and the young people who presented it.[277]

317. While we do think the media has a vital role to play and we also acknowledge the key importance of societal pressures we would not like to conclude our report without drawing attention to the responsibilities individuals must take for their own health. Drawing from the NATSAL, the PHLS point to "substantial increases in high-risk sexual behaviours in the British population", ranging from increases in the numbers of partners over a lifetime, to a higher rate of concurrent partnerships, to an increase in the proportion of gay men reporting unprotected sex.[278] To some extent we have to acknowledge that individuals are making choices, some of which are irresponsible, in that they lay not only themselves but others to risk of harm.

Giving priority to sexual health

318. We began our report by noting the crisis in the nation's sexual health. Nothing in the evidence we have received convinces us that sexual health is yet accorded the priority it deserves. We have looked at failings in treatment service; problems of access to service; poor premises; insufficient numbers of clinicians working in this area; weaknesses in health prevention strategies; and sex education still leaving much to be desired. We were very struck by the fact that we received no evidence either from regional directors of public health, or from directors of public health in Strategic Health Authorities, suggesting that a key layer in the strategic management process is currently neglecting the issue of sexual health.

319. The crisis in sexual health services seems to us a consequence of several factors:

320. During the course of this inquiry, it has become clear that sexual health services in the NHS are not equipped to cope with the rising demand for their services sparked by changing sexual behaviour and an epidemic in sexually transmitted infections. Equally concerning is the fact that in both acute trusts and Primary Care Trusts, even in areas of huge sexual health need, development of sexual health services is being pushed off the agenda by other issues, such as waiting times for elective surgery, where organisations' performance against explicit targets is closely monitored by the Department.

321. NHS organisations have their performance managed in a number of different ways. NHS Trusts are subject to the star rating system, which gives an annual assessment of their performance on nine key targets, 28 wider performance indicators, and Commission for Health Improvement clinical governance reviews. National targets such as waiting times are also monitored by the Department in-year via Strategic Health Authorities. PCTs now produce 3-year Local Delivery Plans setting out how national targets in six areas will be met in their own areas, which are agreed and managed by the overseeing SHA. The targets against which both Trusts and Primary Care Trusts are managed come from a variety of places. Most general targets surrounding access to care originate from the NHS Plan, while the more detailed targets surrounding access to care and quality of care in particular clinical areas are set out in National Service Frameworks.

322. The Government has invested significant priority in the issue of waiting times for NHS services, which it argues is the issue of greatest importance to patients. When treating life-threatening conditions or transmissible infections, gaining diagnosis and treatment as quickly as possible is obviously paramount. This is something that has come out very strongly in our evidence. The Government has put in place a broad range of targets surrounding waiting times, which cover almost every entry point to the NHS: by 2004, patients should have to wait no longer than 48 hours for initial assessment by a GP. If they have urgent problems which require immediate attention in a hospital, their maximum wait at an Accident and Emergency department should be one and a quarter hours. By 2005, if patients require a specialist outpatient appointment for a chronic problem which does not require immediate action, they should be given an appointment within a maximum of three months, and a non-emergency surgery appointment within a maximum of six months. However, access to sexual health clinics remains one area which is not covered by any of these very comprehensive targets.

323. Despite a considerable investment by the Government in targets to improve access to care and to improve health, sexual health is an area which seems to have fallen completely through the net. We understand the concerns of NHS organisations who feel that innovation is oppressed by the imposition of large numbers of centrally managed performance targets, which may not reflect local priorities, and for many organisations the recommendation of further central measures to improve the delivery of sexual health services may be unwelcome. However, at the moment we are in a position where so much NHS activity is currently subject to targets and performance management that those areas where urgent action is needed but which lack central performance management are in serious danger of being deprioritised. We therefore recommend that the Government takes urgent steps to ensure that access to high-quality sexual health services is prioritised and resourced.

324. The best way of achieving this would be the launch of a dedicated National Service Framework for sexual health and we recommend that this be done. We understand, however, that the development of an NSF can take a number of years. Therefore, as an interim step we recommend that the Department should insist that sexual health is tackled, as a public health priority, at a strategic health authority level by adding it to the Planning and Priorities Framework 2003-06. The Department should set in place a rapid and urgent review of sexual health need, services, sexual health promotion, and treatment. This will need to be done jointly with SHAs and PCTs. To ensure that SHAs fully embrace this new responsibility, SHA Directors of Public Health should be responsible for the delivery of a 48-hour access target within their patch within two years, which should be supported by specific targets relating to reductions in the numbers of cases of the major sexually transmitted diseases.

325. We are well aware of the danger of prescribing an NSF as the necessary panacea for any particular problem in the health service. There are numerous competing demands for priority and resources within the health service. However, the dramatic and spiralling decline in the nation's sexual health, the fact that this decline impacts most seriously on the most disadvantaged in society, and the danger that if nothing is done there will be a further deterioration with profound consequences convinces us that this is an area desperately in need of prioritisation. Further, we believe that the process of drawing up an NSF in this area could be expedited. The Strategy and its supporting documents already provide a very substantial basis, meaning that the development timescale could be condensed considerably. The Medical Foundation for AIDS and Sexual Health work on standards and networks could be woven into an NSF. If this option were pursued, in our view, the NSF should contain a maximum access target of 48 hours for access to a GUM or specialist family planning clinic, and be supported by specific targets relating to an eventual reduction in the number of cases of the major sexually transmitted diseases. As with other NSF targets, these should form part of PCT local delivery plans.

326. Each onward transmission of HIV costs the health service hundreds of thousands of pounds and individual countless hours of anxiety, if not serious illness; each case of chlamydia in a young woman has the potential to trigger infertility; each unwanted teenage pregnancy has the potential to damage the life-chances of the parents and children involved. It would be profoundly depressing if a successor Health Committee was to address these issues in ten years' time, only to find evidence of a further deterioration of sexual health in this country. We have been appalled by the crisis in sexual health we have heard about and witnessed during our inquiry. We do not use the word 'crisis' lightly but in this case it is appropriate. This is a major public health issue and the problems identified in this Report must be addressed immediately.

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275   Q266 Back

276   Q356 Back

277   See for example Simon Hoggart, "Fixed Smiles greet the sex revelations of Sarah", The Guardian, 17 January 2003; Frank Johnson, "Commons Sketch", Daily Telegraph, 17 January 2003; Simon Carr, "Let's not talk about sex and geography", The Independent, 17 January 2003. Back

278   Ev 57 Back

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