Sexual health Contents


121.Securing a safe, well trained, supply of staff is imperative to the delivery of good sexual health services. The sexual health workforce is varied and includes a broad range of medical and non-medical, specialist and non-specialist staff providing services from hospital, primary care and community settings:

122.Over the course of our inquiry we have heard first-hand from staff about the pressures they face around system change and rising demand, and concerns about the impact of pressures on morale, retention and recruitment.


123.Morale amongst the sexual health workforce is low.150 The British Association of Sexual Health and HIV describe staff morale as at “breaking point”. Of respondents to their 2018 members survey, 81% reported that staff morale had decreased within their service in the past year with 49% reporting that staff morale had greatly decreased.151

124.This situation is attributed to the pressures the workforce faces: organisational change, funding cuts, heavy demand and service closures have put pressure on staff. Practitioners at our focus group in Plymouth told us that working in sexual health was seen as insecure, and staff feel uncertain about the future of sexual health services. We heard that the sexual health workforce feel a lack of parity with NHS staff.152 The British Association of Sexual Health and HIV told us the experience of their members:

Demand for the service continues to increase, we have high levels of sickness and staff are exhausted

All staff have experienced adverse reactions and our complaints and incidents have risen significantly.153

Retention and recruitment

125.Low morale has contributed to challenges in retention and recruitment: uncertainties and pressures in the sector have made working in sexual health less attractive to both new and existing staff.154 The current workforce is ageing and leaving.155 A diminishing pipeline of staff makes this situation particularly challenging. 65% of respondents to the British Association of Sexual Health and HIV’s 2018 survey reported that it had become more difficult to recruit appropriate staff in the past year.156 People are not being trained to replace the skills lost when people retire. CSRH and GUM consultants play a key leadership role in supporting the nursing and general practice workforce to deliver all aspects of sexual health. The Faculty of Sexual and Reproductive Health argue that the sexual health consultant workforce is in a “succession crisis” and estimate that one-third of this workforce could retire in the next 5 years.157

126.As a specialty GUM used to be very competitive, but there has been a crash in demand for GUM specialisation, and now it is the least popular. The Specialist Advisory Committee for Genitourinary Medicine told us that recruitment to GUM training programmes is in “crisis” and “doctors no longer wish to train as Genitourinary Medicine Specialists due to the career instability.” The output of training falls short of replacing vacancies that will arise due to retirement. Applications to training posts have declined, and in 2018 less than 40% of posts advertised were filled (figure 5).158

Figure 5: applications to GUM training posts have decreased

Source: Specialist Advisory Committee for Genitourinary Medicine

127.In contrast, CSRH speciality training programmes are competitive, yet also still fall short of replacing vacancies, let alone address the fact that current numbers are inadequate.159 The Royal College of Nursing states that the recruitment of nurses is also a key area of concern, with members reporting that sexual health is not regarded as attractive to new staff.160


128.Retention and recruitment difficulties are exacerbated by diminished training opportunities: limited learning and development opportunities feed into the decreasing attractiveness of working in sexual health.161 Training across multi-disciplinary teams is vital, but training is falling through the gaps.162 We heard that although services would like to build capacity and develop the clinical and wider workforce, they are not incentivised to invest in training. At our roundtable in Plymouth clinicians told us that taking time out, and finding the money, to do specialist training in the context of an overstretched service is challenging.163

129.The Royal College of GPs raised significant concerns around training to develop and maintain competency in LARC fittings. As discussed previously, LARC is one of the most effective forms of contraception but use is relatively low. This has been in part attributed to reduced provision in primary care due to problems with commissioning and funding. We have also heard that access to training in the provision of LARC is a factor. The Primary Care Women’s Health Forum found in 2017 that almost one-third of respondents had seen reduced access to training to provide LARC. The Royal College provided anecdotal evidence from a GP in England:

With GP recruitment so difficult now, gone are the days when a new GP had to have SH qualifications. Our last 2 appointments do not have SRH experience. I am the sole LARC fitter to a practice population of 11,500 and aim to retire in a few years’ time.164

130.We have heard that the move to local authority commissioning and competitive tendering has exacerbated issues around training—the NHS prioritise training to a greater extent.165 Training is not included in service specifications, and an organisation may win a contract to provide a service and not take part in training programmes.166 We were told that providers should not be able to ‘opt out’ of training in this way.167

131.The Minister recognised that training the future sexual health workforce is an issue that is falling through the gaps. The Minister assured us that the Harding review—the development of the workforce plan to go alongside the NHS Long Term Plan—would take a joined-up approach to the future workforce. The Minister stated that this review would look at sexual health, including the issue of providers being able to ‘opt-out’ of training.168

Conclusions and recommendations

132.Development of the sexual health workforce, including training, has been given insufficient priority. Training across multi-disciplinary teams is vital, but is falling through the gaps in the face of other pressures providers face.

133.It is clear that fragmented arrangements for the commissioning and provision of services have meant that workforce planning, development and training have suffered. The Harding review should set out a deliverable plan for the workforce needed to deliver sexual health services across England in the next 10 years. Meanwhile, the national sexual health strategy should include a clear programme of further action to re-establish training and development for both the current and future sexual health workforce at the heart of commissioning and provision arrangements.

150 Q51; Royal College of Nursing (SLH0078)

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

152 Annex 2

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

154 Royal College of Nursing (SLH0078); Annex 2

155 Q51; Annex 2

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

157 Faculty of Sexual and Reproductive Healthcare (FSRH) (SLH0027)

158 Annex 1; Specialist Advisory Committee for Genitourinary Medicine, Joint Royal College of Physicians Training Board (SLH0029)

159 Faculty of Sexual and Reproductive Healthcare (FSRH) (SLH0027)

160 Royal College of Nursing (SLH0078)

161 Royal College of Nursing (SLH0078)

163 Royal College of General Practitioners (SLH0075)

164 Royal College of General Practitioners (SLH0075)

165 Annex 2

167 Annex 2

Published: 2 June 2019