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 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
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
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.
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
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
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 servicesWe
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
10. Payment by resultsWe
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
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 overallcontraception
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 PracticeWe 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 contraceptionone 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 professionalsIn
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
21. Prioritisation at local levelDespite
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 (2005-062007-08) 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
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 servicesDespite
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.
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
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
2 For further information about these recommendations
please see fpa's report Early abortions: promoting real
choice for women, December 2003. Back