Sexual health Contents

2Services

62.Sexual health services have been described by the Local Government Association as at ‘tipping point’.76 This situation is ascribed to increased demand in the face of reduced funding and fragmented commissioning. There are issues around accessibility, especially for groups particularly vulnerable to poor sexual health outcomes. There are concerns about quality of care, and the provision of certain services is inadequate and inequitable.

Quality of care

63.The service users we heard from broadly praised the care provided by staff, telling us that they had been kind, reassuring and non-judgemental. Service users also noticed that staff were under pressure, and that this affects services (case examples 2). Professor McManus highlighted that unmanageable pressures on staff can mean that that they are unable to “go the extra mile” for service users:

My experience of my providers, and many providers up and down the country, is that they absolutely go the extra mile. Where people do not go the extra mile, it is because they are either burned out or exhausted.77

Case examples 2: service user views on quality of care

The quality of care I received following a sexual assault was incredible. I was looked after, everything was explained to me and they didn’t rush me. (bisexual woman aged 18–24)

As a man living with HIV for the past 6 years I have had almost uniformly excellent care, from health workers who are knowledgeable, considerate and highly professional. (homosexual man aged 36–45)

Quality of care: faultless – all clinical staff are friendly, professional, and non-judgemental. I think that many people who attend a sexual health clinic are scared or anxious, but the staff at [redacted] are amazing. (heterosexual woman aged 18–24)

The staff are always friendly but they clearly are stressed out with more patients to see. (homosexual man aged 46–60)

Source: Summary of survey responses received

Accessibility

64.Accessibility was the primary concern of the service users we heard from. They reported difficulties booking appointments, long waits at walk in sessions, impractical opening times, inconvenient locations and closures.

Case examples 3: service user views on accessibility

At one clinic booking was almost impossible. You could only get an appointment in a two minute window twice a week before all were booked. Another clinic’s system said they would phone back to book an appointment, and they never did.

It’s hard to get an appointment with my GP surgery as you have to book three weeks in advance. (bisexual woman aged 18–24)

Even though I arrived as early as possible I still had to wait for a good 4 hours before getting an appointment, I was so happy with the service but the wait time was crazy for a midweek appointment. (bisexual woman aged 18–24)

Also most sexual health clinics are only open at specific times during the week, often a weekday during the day. This means that I would have to take time off work to attend. (heterosexual woman aged 25–35)

A few years ago I could get an appointment in several clinics quite easily, now I have to try and book appointments and a lot of the old clinics I visited have shut down. (homosexual man aged 46–60)

I would feel more confident to go to a clinic but they are far from where I live. (heterosexual woman aged 18–24)

Source: Summary of survey responses received

65.This patient perception is echoed in reports from those providing sexual health services. Written evidence from individual practitioners suggests that service closures are a problem in many parts of the country:

i)In London seven services closed in the last year;78

ii)In Dorset one walk-in service closed, five outreach clinics closed, two evening clinics at the hospital closed and a LGBT service moved to smaller, less convenient premises;79 and

iii)In Surrey one service closed, resulting in patients having to travel additional distances to access remaining services.80

66.Services that have remained open also report problems with access—in a recent membership survey carried out by BASHH, 54% of respondents reported that access to their service had decreased, and 63% of respondents reported that they have to turn away patients on a weekly basis.81 Dr Williams described how “some services across the UK are turning away more than 50 people a week; they cannot physically see them in the department, because there is no capacity.”82 Evidence from Public Health England agrees that there has been a reduction in access:

Evidence from a survey of lead GUM physicians suggests that, while the majority of clinics could still offer appointments within 48 hours, there has been a decline in access for symptomatic patients and even lower levels of access for asymptomatic women.83

67.Reductions in access are also apparent in relation to contraceptive services. The Advisory Group on Contraception found that almost half of councils in England have closed sites providing contraceptive services since 2015. Public Health England states that one-third of women are not able to access contraception from their preferred provider.84

68.According to the Royal College of GPs, services in one area can be vastly different to another, which has led to “disrupted, disconnected and ultimately disappointing experiences for patients.”85 We have heard this from service users.86

69.Good access to sexual health services is not only a matter of patient convenience. Sexual health services are essentially preventative services - diagnosing and treating an STI promptly helps prevent onward transmission, and good access to effective contraception services helps prevent unplanned pregnancies.

70.One area of provision that has expanded overall is online services such as self-testing and postal prescribing.87 BASHH argued that

Where sexual health has been really innovative over the last year is in adopting modern technology. It has embraced and empowered the patient group to take self-testing on board and to get text results.88

71.We heard in detail about the digital sexual health service being set up in Plymouth, and it was also described by service users in our online survey:

Case examples 4: service user views on online services

More online testing services as it is difficult to attend clinics when working full time and they’re often full up. Some boroughs have online services, and this should be free to all across the country. People are probably more likely to check their sexual health if they can do it in the convenience of their home without having to find time to attend a packed clinic that doesn’t offer appointments. (heterosexual woman aged 25–35)

Source: Summary of survey responses received

72.While there was broad support for increasing online services, we heard that they should not be driven by cost savings or commissioned in isolation or in lieu of existing services:

The shift to online testing has been reasonably successful, but it is not appropriate for everyone - those who are digitally excluded, for example. There are people who actually have multiple concerns about their sexual health, and going down a questionnaire and being sent an online test is not the most appropriate thing for them. There are people who have language barriers, and all sorts of things.89

73.Clinicians and commissioners at our focus group agreed that it should not be seen as a “silver bullet”.90

Vulnerable groups

74.Problems with accessibility disproportionately affect certain population groups, to the extent that some groups have inadequate access to sexual health services. Professor Newton told us that vulnerable groups—intravenous drug users, rough sleepers, recent migrants and victims of sexual violence—find it most difficult to access services.91 Witnesses also told us that groups who are disproportionately affected by poor sexual health outcomes—young people, MSM and BAME—struggle to access some services.92 We heard that the most vulnerable, chaotic or deprived are the ones that often cannot navigate the financial, social or cultural hurdles to access services. The changes in access described above, such as service closures, have particularly troublesome impacts on these groups.93 The Royal College of GPs gave us this example:

I work in the centre of Bradford, where the cuts hit the most deprived most severely, because they cannot always negotiate the social, cultural or financial factors; they cannot navigate the hurdles put in their way when access is changed. We know that increased inequalities are occurring across the system, with reduced access … .women with busy lives, either working or with children, cannot go from one service to another because they just do not have the time. They neglect their own health.94

75.This was echoed by the Faculty of Sexual and Reproductive Health:

What happens then is that the most vulnerable in our society suffer; the woman with the pram cannot navigate her way through the system and get access to her needs. As a consequence, the use of long-acting, reversible contraception—there is good NICE guidance suggesting that it is the best form—is decreasing.95

76.Nearly half of respondents to a recent survey conducted by the British Association of Sexual Health and HIV reported a reduction in the provision of care to vulnerable populations.96 In recent years sexual health service contracts have become larger, and may be predominately designed with the majority in mind, lacking incentives to seek out complex, hard-to-reach patients, who need longer and more frequent consultations.97 Targeted service provision, including outreach and other forms of assertive provision, has reduced. Marion Wadibia, Chief Executive of the NAZ Project London, told us that

… the tailored and targeted approach that we know works with smaller groups and those who do not necessarily come forwards has been absolutely decimated.98

77.We heard that although there is a place for a more universal approach, it should not be at the expense of targeted service provision.99 Targeted provision is important for meeting the needs of specific population groups: the skills, knowledge and networks of targeted services mean they can better reach and support the specific groups they serve.100 As Marion Wadibia said, “something needs to be relevant to you.”101 The NAZ Project London noted that their service’s grounding in BAME experiences of race, culture and sexuality—that they ‘spoke the language’ of their service user—was key to the service’s success.102 Brook told us that limiting provision specifically for young people leaves them to ‘fend for themselves’ in adult services. Adult services generally do not have the same kind of expertise, so safeguarding issues may be missed.103 Regarding the LGBT experience, we heard from Stonewall that whist LGBT people reported being discriminated against by health services in general, in fact their experience was more positive in sexual health services than in other types of health service.104 However inequalities exist within the LGBT population, with gay and bi women and trans people less likely to access sexual health services than gay and bi men, and more likely to report poor experiences.105

78.Witnesses told us that more needs to be done to ensure that services are designed in a way that meets the needs of all groups. We heard that a needs assessment that identifies the requirements of the local population, including the specific needs of certain groups, must be the base from which a service is built.106 Services must be designed around meeting the needs identified, so that there is a pathway for every population.107 We heard that the best commissioners currently do this, but that it must be done as standard.108 Local accountability (for example to health and wellbeing boards) is currently not adequate to ensure that happens, pointing to a need to strengthen accountability at the national level.

Conclusions and recommendations

79.There is no doubt that care is being delivered by committed professionals, and service users told us the quality of care they received was good. However, access to sexual health services is worsening and is a particular problem for vulnerable groups. To address this, national quality standards should be developed, setting out in detail a consistent basis for best practice across the country. These standards should be developed by the national sexual health working group in consultation with service providers and patients. As a minimum they must cover access, and the provision of services which meet the needs of vulnerable populations.

Testing and screening

80.Currently there are gaps in testing for certain emerging STIs. The integrated sexual health tariff has pathways to fund testing for chlamydia, gonorrhoea, HIV, syphilis and hepatitis A and B. However, funding is not directly there for trichomoniasis vaginitis (TV), an infection that increases the risk of HIV acquisition in women if untreated. This particularly affects BAME women and we have heard that it should be tested in a targeted way, including through online testing.109

81.Funding is also not provided for testing for mycoplasma genitalium (MG). MG is a growing concern: the lack of testing for MG is causing to it being incorrectly diagnosed and treated as chlamydia, which is leading to anti-microbial resistance. Lack of funding for MG testing was particularly raised by attendees at our focus groups.110

82.We heard that although some sexual health services are testing for MG and TV without funding, the majority of sexual health services are not, given the increased costs associated with doing so.111

83.A further concern is around testing the antimicrobial sensitivities of gonorrhoea, to ensure appropriate treatment and prevent the development of antimicrobial resistance, as Dr Williams described:

Quite a lot of clinics do not have access to culture for gonorrhoea, so they treat someone with gonorrhoea blindly, in a way, not knowing what their antimicrobial sensitivities are.112

84.PHE agreed that there was ‘variability’ in the availability of these tests.113

85.Funding is not currently provided for testing for mycoplasma genitalium (MG) and trichomoniasis vaginitis (TV) STIs. Although some sexual health services are testing for MG and TV without funding, the majority of sexual health services are not, given the increased costs associated with doing so. This is a significant concern. We are equally concerned by the fact that full testing for gonorrhoea is not available in all STI clinics, potentially fuelling the rise in multi-drug resistant, untreatable strains of this serious illness. All STI clinics should be funded to provide a full range of STI testing, including MG, TV and gonorrhoea, and this should be clearly set out in the national quality standards.

Cervical screening

86.As cervical screening rates have fallen to a 20-year low, it is clear that every opportunity to offer screening to women should be maximised. However, we were told about the absurd situation in some areas, where a patient having a coil fitted at a clinic cannot have a smear test done at the same time, even when they need a smear test and the clinician is trained to do it, because fragmented commissioning arrangements mean that many sexual health clinics are not funded to provide cervical screening:

In my clinic last week I saw a patient for a complex coil fitting. She was due her smear but I could not do it. I am able to do it, because I am a trained colposcopist, but the commissioning arrangements are such that the service is unable to provide the smear.114

87.This is not only a wasted opportunity for testing and an inefficient use of resource, but it is distressing for the patient to have multiple intimate examinations. Dr Connolly, Clinical Champion for Women’s Health of the Royal College of General Practitioners described it not only an “insult that a woman has to be examined so many times” but in fact an “assault”.115

88.Inequalities in access to cervical screening were raised as an issue by attendees at our focus groups, and Public Health England echoed these concerns. When we put these concerns to NHS England we were told that concerted action was now being taken to address this problem, and that they will be introduced as a standardised part of commissioned services by 2021.

89.Cervical screening is a life-saving intervention for a cancer which is largely preventable, yet still claims two lives a day. However, cervical screening rates have fallen to a 20-year low. We were shocked to hear how fragmented commissioning arrangements mean that in some parts of the country, women are not able to have cervical screening done at the same time as other sexual health provision.

90.Cervical screening must be clearly included as part of national quality standards for sexual health. But there is a need for more urgent action on this issue to save lives and prevent women having to undergo a second examination for a test that could and should be completed at a single visit. We call on PHE and NHS England to set out what immediate actions they are taking to address this in their response to this report.

Long Acting Reversible Contraception

91.Long Acting Reversible Contraception (LARC) is the most effective type of contraception available, and more widespread availability and promotion of LARC has been credited, at least in part, with reducing teenage pregnancy rates.

Long Acting Reversible Contraception [LARC]

There are four long acting reversible contraception methods – intrauterine device/system, contraceptive injection or implant. Once any of these are in place, you don’t have to think about contraception each day or time you have sex.

  • Contraceptive implant – a small flexible rod inserted under the skin of the upper arm. It slowly releases progestogen into the body, stopping the release of an egg from the ovary.
  • Contraceptive injection – also releases progestogen into the body and last between eight and 13 weeks depending on which one you have.
  • Intrauterine device/ system (IUD/ IUS) – a small T-shaped copper or plastic device that is inserted into the womb. It works by stopping the egg and sperm from surviving in the womb or the fallopian tubes.

Source: iCASH

92.However complexities in commissioning and funding have contributed to a reduced provision of LARC in primary care, which is where the majority of women access contraceptive services. The RCGP state that GPs are not financially incentivised to deliver an enhanced, or even core, provision of contraceptive services, and describe a reversal in the quality of clinical care: “we are going back quite a long way from the benefits we were seeing from good access to all contraception.”116

93.Service users told us about issues around contraceptive services delivered by primary care (case examples 5).

Case examples 5: service user views on contraception

I believe that most contraception should be available in GP’s, like the injections, pills and possibly the implant as they are all fairly simple procedures and would save a lot of people a lot of time. (heterosexual woman aged 18–24)

GP services on contraception vary massively between the two areas I have lived. In [redacted] I was never invited to consider any other type of contraception except for the pill. On moving to [redacted] I was invited to consider a whole range of other contraception and decided to go for the IUS [intrauterine system] coil, which was then fitted within the GP surgery. (bisexual individual aged 18–24)

Source: Summary of survey responses received

94.At our focus group, we heard about good practice in extending access to GP-based provision of care in one part of the country, but reductions in many other areas.

95.Long Acting Reversible Contraception (LARC) is the most effective way of preventing unplanned pregnancy, and its more widespread availability has been credited with reducing teenage pregnancy rates. However, we are very concerned to hear that because of changed commissioning and funding arrangements, many women are no longer able to access some forms of this method of contraception, leading to a 13% drop in its use. Action must be taken to reverse this worrying trend. Access to LARC at all locations where sexual and reproductive health services are provided—including primary care—must form a key part of the national quality standards.

Pre-Exposure Prophylaxis for HIV

96.HIV pre-exposure prophylaxis (PrEP) is a medication taken to ensure individuals vulnerable to HIV acquisition remain HIV negative, and has been shown to be fully effective.117

97.In 2016, following the finding in the PROUD trial of an 86% reduction in new infections in MSM taking PrEP, NHS England announced a decision not to put it on the list of specialised commissioning treatments, arguing that it did not have the power to do so, and claiming that HIV prevention was the responsibility of local government. Several commentators disagreed at the time, and the National AIDS Trust, arguing that under the Health and Social Care Act 2012, NHSE could commission services directly, requested a judicial review by the High Court. This, and a subsequent appeal, determined that the NHS did have the power to provide PrEP.

98.NHS England is currently undertaking a PrEP Impact Trial to address outstanding questions around need, uptake and duration of use. NHS England and the Department told us that it will be important to examine the findings of the trial before national roll out, including around specific population groups, financial implications, any impact on STI rates and consequential system pressures, and any other unintended effects.

99.NHS England allocated £10 million for this trial, full results from which will be available in early 2020. NHS England and the Department argue that it will be important to examine the findings of the clinical trial before national roll out. Some interest groups have called for PrEP to be rolled out faster than proposed. The National AIDS Trust (NAT) call for a programme starting in April 2019.118 The Terrence Higgins Trust also calls for routine commissioning of PrEP as a matter of urgency, and in the meantime, scrapping the cap on trial places.119 Attendees at our focus groups laid bare the geographical inequities in access to PrEP,120 and we also heard from service users about this:

Case examples 6: service user views on PrEP

PrEP needs to be available on the NHS in England. I asked for it but I was told that the trial was full up and that I would have to buy PrEP online at some cost. I am unable to afford this and so I feel let down by NHS England for not being able to provide a service which is otherwise available elsewhere on the UK. (homosexual man aged 25–35)

The NHS should provide more funding and places for the PrEP trial in England. This is a drug that while it has a cost now, in the long run will save the NHS significantly more by not having to pay for HIV management medication. (homosexual man aged 36–45)

Source: Summary of survey responses received

100.There is huge frustration amongst both patients and clinicians about the current inequitable access to PrEP, a new treatment which can prevent HIV. We note that NHS England has expanded its pilot sites to increase the number of people able to benefit from PrEP, but access remains a postcode lottery. We call on NHS England to review whether it is unreasonably restricting access to PrEP due to disputes about funding pathways rather than questions about its effectiveness. PrEP should also be covered within the national quality standards—if it is deemed to be an effective and cost-effective treatment it should be universally available.


76 Local Government Association (SLH0050)

78 Dr Matthew Grundy-Bowers (SLH0030)

79 Dr Alison Vaughan (SLH0079)

80 Dr Amy Bennett (SLH0073)

81 British Association for Sexual Health and HIV / British HIV Association (SLH0042)

83 Public Health England (SLH0087)

84 Public Health England (SLH0087)

85 Royal College of General Practitioners (SLH0075)

87 London Councils (SLH0049)

89 Dr Williams, Q15

90 Annex 2

93 Q4; Q10

94 Royal College of General Practitioners (SLH0075)

95 Q3

96 British Association for Sexual Health and HIV / British HIV Association (SLH0042)

97 SHRINE (Sexual and Reproductive Health Rights, Inclusion and Empowerment) (SLH0021)

100 Brook (SLH0032)

102 Naz Project London (SLH0090)

103 Brook (SLH0032)

104 Laura Russell, Q65

105 Laura Russell, Q65

106 Brook (SLH0032); Stonewall (SLH0056); Q104; Qq73–75

108 Annex 2; Q104

109 Brook, Q67

110 Annex 2

111 Imperial College Healthcare NHS Trust (SLH0076)

112 BASHH, Q8

117 Terrence Higgins Trust (SLH0048)

118 NAT (National AIDS Trust) (SLH0055)

119 Terrence Higgins Trust (SLH0048)

120 Annex 2




Published: 2 June 2019