Select Committee on Health Minutes of Evidence

Memorandum by fpa (HA 08)


    —  fpa (Family Planning Association) is the UK's leading sexual health charity working to improve the sexual health and reproductive rights of all people throughout the UK.

    —  The consequences of the new and proposed changes in charges for overseas patients with regard to access to HIV/AIDS services:

—  We are concerned that the proposed changes will act as a disincentive for testing, which will have serious implications for public health.

—  There could also be a knock-on effect on Accident and Emergency services if treatment is denied in primary care.

    —  Progress to date in implementing the recommendations of the Committee's inquiry into Sexual Health (the Committee's Third Report of Session 2002-03):

—  fpa welcomes the Public Health White Paper proposals on sexual health and the additional funding of £300 million announced to implement these proposals.

—  We believe that there needs to be much greater integration of sexual health services, in particular an increase in the number of services which offer both contraceptive and STI services, and greater integration between contraceptive and abortion services at the funding and commissioning level.

—  We are very concerned that payment by results will act as a disincentive for integrated and effective sexual health services.

—  It is vital that contraceptive services are improved, and that general practice provision of contraception is including in the forthcoming audit.

—  There is a real need for improvements in general practice provision of sexual health services, with additional quality points and clarification of services covered in the GMS contract.

—  All professionals working in sexual health must have access to good quality training which includes communications skills.

—  There must be further prioritisation of sexual health at a local as well as a national level.

—  Despite the omission of abortion services from the Public Health White Paper, there must be continued improvement in and access to these services for all women.


About fpa

  1.   fpa welcomes the opportunity to contribute to the Health Select Committee's inquiry into New Developments in HIV/AIDS and Sexual Health Policy. We are also willing to give oral evidence at the evidence session on 27 January 2005.

  2.   fpa (Family Planning Association) is the UK's leading sexual health charity working to improve the sexual health and reproductive rights of all people throughout the UK. fpa wants to see a society with positive and open attitudes to sex, in which everybody enjoys sexual health and where sexual and reproductive rights are respected. fpa's purpose is to enable people in the UK to make informed choices about sex and to enjoy sexual health free from exploitation, oppression and harm.

  3.   fpa runs a comprehensive information service, including a national telephone helpline, which responds to over 100,000 queries each year on a wide range of 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 and sex and relationships education (SRE). We also contribute to SRE through our series of publications aimed at young people which schools can use as part of their SRE programme.

The consequences of the new and proposed changes in charges for overseas patients with regard to access to HIV/AIDS services

  4.  This is not a specific area of expertise for fpa, but we do make the following general points:

  5.  As we understand it, in relation to access to HIV/AIDS services, only diagnostic testing and associated counselling will be exempt from charges. We are concerned that this will act as a disincentive for overseas patients to come forward for testing, as they will have to pay for treatment following a positive result. Given the nature and transmission of HIV, it is vital that people are tested and treated as quickly as possible. The public health consequences of undiagnosed HIV are significant. If people are denied access to HIV testing and treatment they are likely to pass infections on to future sexual partners, thereby increasing infection rates in the population as a whole.

  6.  Furthermore, diagnoses must be made quickly in order to limit complications which can in turn impact on acute services. If overseas patients are denied treatment in primary medical services, they are more likely to present to Accident and Emergency services where emergency treatment is free.

Progress to date in implementing the recommendations of the Committee's inquiry into Sexual Health (the Committee's Third Report of Session 2002-03)

  7.   fpa welcomes the inclusion of sexual health as a central theme in the Public Health White Paper and the injection of £300 million for sexual health services over the next three years. This is an excellent step forward in improving people's sexual health and should help to accelerate the achievement of the recommendations laid out in the Health Select Committee Report. However, the real test will be in how quickly and effectively implementation of these comprehensive proposals can take place at a local level.

  8.   Integration of sexual health services—We believe that better sexual health choices could be made available to users through the integration and joining-up of services, so that, for example, people can access STI screening at a family planning clinic and contraceptive services at a GUM clinic. There needs to be an increase in the number of services which offer both contraceptive and STI services, so that there is a more holistic approach to people's sexual health. It would not be necessary to have a combined service in every setting, but GUM and family planning services should be linked together and seen as part of one sexual health service.

  9.  There also needs to be greater integration between contraceptive and abortion services at the funding and commissioning level. It is self-evident that where there are high quality and easily accessible contraceptive services there will be fewer unintended pregnancies and therefore fewer abortions. There are currently very few PCTs which integrate either funding or commissioning of these services, which means that there is no financial incentive to get the best out of both services. We believe it is an urgent priority for PCTs to recognise the links between contraceptive and abortion services and to integrate their approach accordingly.

  10.   Payment by results—We are concerned that payment by results will act as a disincentive for integrated sexual health services if services are paid for separate family planning or GUM consultations. This will result in service users being pushed to a number of different services rather than having a holistic service that can offer both GUM and family planning advice and treatment. There is a concern that if service users are referred to a separate service, they will not attend another appointment so may not access the services they need.

  11.  In addition, if services are organised so that payment is by visit rather than by treatment, this does not take into account provision of longer-term courses of treatment. For example, in contraceptive services, this could militate against provision of longer-acting contraceptives which last for a number of years (eg IUDs, implants, etc), and could instead incentivise repeat prescriptions of oral contraceptives at more frequent intervals.

  12.   Quality of contraceptive servicesfpa welcomes the announcement in the Public Health White Paper that there will be an audit of contraceptive service provision to be carried out in 2005, followed by central investment to meet gaps in local services (following recommendations 29 and 31 in the Select Committee Report). We believe that it is vital that general practice contraceptive provision is included in the audit as well as family planning clinics.

  13.  Wherever users access contraceptive services, they must have access to all contraceptive methods. Anecdotal evidence suggests that not all services currently offer all methods, in particular in general practice where the majority of contraceptive advice is given. It is particularly important to prioritise contraceptive services overall—contraception is a positive health service, is the ultimate preventive tool in sexual health, and currently saves the NHS around £2.5 billion per year.

  14.   Impact of the GMS contract on sexual health services provided in General Practice—We are very concerned that out of the 1,050 quality points in the National Quality and Outcomes Framework in the new General Medical Services (GMS) contract, only two relate to contraception—one on a written policy for emergency contraception, and the second on a written policy for providing pre-conceptual advice to women who want to become pregnant. We believe that this lack of quality points for the provision of contraceptive advice seriously undermines this aspect of the contract, and does not incentivise general practice to provide a comprehensive contraceptive service. These concerns about primary care provision of sexual health services were highlighted in recommendations 28 and 30 in the Select Committee Report, and still remain to be adequately addressed.

  15.  We believe that the Department of Health must also work with the British Medical Association to provide clearer guidance on the impact of the GMS Contract on the provision of STI services in general practice. As we understand it, provision of information, advice, testing and referral for STIs is included within the management of patients required in essential services, but we hear anecdotally that some general practices are declining to offer these services in the mistaken belief that they are not covered in essential services. This situation must be clarified as soon as possible.

  16.  As the GMS Contract is developed, we urge the introduction of additional quality points for contraceptive services, for the diagnosis and treatment of STIs in general practice, and for sexual health promotion.

  17.   Training/support for professionals—In order to create better choices in sexual health we believe that professionals working in primary care need to receive improved information and training. In particular, we believe that greater attention needs to be paid to the role of general practice in providing sexual health services, and to the needs of those who work in general practice for adequate education, training and support on all areas of sexual health.

  18.  It is encouraging that the Public Health White Paper sets out that sexual health services will increasingly be delivered by a flexible, multidisciplinary workforce, including nurses, youth workers, community workers and pharmacists. However, it is vital that all those involved in the delivery of these services are appropriately trained. Sexual health is a sensitive area, and communication skills of professionals working in sexual health services are vital to reduce the "embarrassment factor" during user appointments. Sexual health training should cover attitudes and values, and must include communication skills to ensure a sensitive and non-judgemental approach to service users.

  19.  Similarly, the proposed NHS-accredited health trainers must have adequate training in sexual health as well as other aspects of public health, in order to be able deliver effective support and advice to all groups in communities.

  20.  We are also concerned about the lack of sexual health training required as part of the GMS Contract. In particular, while we welcome the fact that general practices which offer contraceptive services will now be required to offer information and advice about the full range of contraceptive methods, we are disappointed that there is no training requirement attached to this.

  21.   Prioritisation at local level—Despite the National Strategy for Sexual Health and HIV, there has been a failure by local NHS organisations to recognise and deal with sexual health as a major public health issue. Currently, sexual health is given low priority amongst NHS planners and commissioners at both SHA and PCT level. To enable sexual health services to meet the increasing demands placed on them and expand their services accordingly, sexual health and HIV must be a national and local priority for the NHS.

  22.  The Public Health White Paper has made a step forward in ensuring local prioritisation of sexual health: National Standards, Local Action: Health and Social Care Standards and Planning Framework (2005-06—2007-08) will now include improving sexual health within the national targets for the NHS, and sexual health will be included in the forthcoming round of Local Delivery Plans. In this context, it is crucial that future sexual health targets include contraceptive services as well as GUM services.

  23.   fpa is keen to see further measures to ensure that sexual health is embedded and mainstreamed as an ongoing priority for PCTs and SHAs, which is fully accounted for in core budgets at a local level beyond the 3-year timeframe of the recently announced additional Department of Health funding.

  24.   Abortion services—Despite the Health Select Committee's recommendations on abortion services (7, 32 and 33), fpa was disappointed that the recent Public Health White Paper did not include any initiatives on abortion services. fpa believes that, having taken the decision to end a pregnancy, all women should be able to access abortion services promptly and without delay. We recommend that there should be a target waiting time of 72 hours for abortion, with one week as a minimum standard. In the meantime, it is crucial that the Government retains the National Strategy for Sexual Health and HIV's target that from 2005, commissioners should ensure that women have access to abortion within three weeks of the first appointment with the GP or other referring doctor. It is also important that the Healthcare Commission retains its PCT performance indicator of the percentage of NHS-funded abortions performed under 10 weeks.

  25.  Many women face long and unacceptable waits for an abortion to be carried out in a hospital. We believe that early medical and surgical abortions could be carried out in community settings such as family planning clinics and general practices, thereby making use of existing settings and enabling greater access and choice for women. At the same time, we believe that nurses should be allowed to play an expanded role in abortion procedures. This would not only increase the number of professionals working in abortion services and thereby improve access and waiting times, but would also fit in with the broader NHS strategy of developing nurses' skills and specialisms.[2] These recommendations would require a legislative change.

  26.  We are also concerned that women are not currently able to access the abortion services to which they are legally entitled. Anecdotal evidence suggests that women presenting at later gestations find it difficult to access NHS abortion services. We are aware that, in some PCTs, this can be from as early as 13 weeks' gestation, and certainly in many parts of the country difficulties in access are more common from 16-18 weeks' gestation onwards.

  27.  Despite the omission of such specific recommendations in the Public Health White Paper, we believe it is vital for the Government to take additional steps to improve abortion services.

December 2004

2   For further information about these recommendations please see fpa's report Early abortions: promoting real choice for women, December 2003. Back

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