Sexual health Contents

Conclusions and recommendations

Overview – a new national strategy

1.We recommend that Public Health England, in collaboration with a broad-based working group of representatives drawn from all sectors involved in commissioning and providing sexual health services, should develop a new sexual health strategy, to provide clear national leadership in this area. The rest of this report—covering funding, commissioning, services, prevention, and the sexual health workforce—sets out the key areas that this strategy should focus on. (Paragraph 15)

Funding and commissioning

2.Sexual health must be sufficiently funded to deliver high quality sexual health services. Cuts to spending on sexual health, as with other areas of public health expenditure, are a false economy. Looking forward to the Spending Review, the Government must ensure sexual health funding is increased to levels which do not jeopardise people’s sexual health. Inadequate prevention and early intervention increase overall costs to the NHS. (Paragraph 52)

3.As part of work to develop a new national sexual health strategy, we recommend that the national sexual health working group should set out the minimum levels of spending that will be required to ensure that all local areas are able to deliver high quality services. (Paragraph 53)

4.A wholesale reorganisation of commissioning responsibilities—moving responsibility for sexual health back to the NHS—is not the answer to the problems with commissioning which our witnesses have identified. As our predecessors concluded in their report on Public health post-2013, there is a need to address system boundary issues in the best interests of patients. Strengthened collaboration is key, and longer contracts should be introduced to enable better strategic planning and to lessen the burden that tendering currently imposes. (Paragraph 56)

5.The national sexual health strategy, supported by a senior working group, must bring new impetus to work to drive forward change and improve services for patients. (Paragraph 57)

6.Recognising the complexity of the provider and commissioner landscape in sexual health, the national sexual health working group should consist of senior representation from all relevant groups, including PHE, NHS England, local government, patient representatives, CCGs, and different provider groups. (Paragraph 58)

7.Building on the recommendations set out by the ADPH and PHE 2017 review, the strategy should aim both to identify and to disseminate best practice, and to work supportively but robustly with areas which need to improve. (Paragraph 59)

8.The strategy should set out one clear set of national quality standards for commissioners to adhere to, encompassing all aspects of sexual health. The standards should provide a holistic and unified overview of what good looks like, including setting out how all services should work together, and setting out standards for effective commissioner behaviour. Further recommendations for what these quality standards should include are set out in subsequent chapters. (Paragraph 60)

9.The national sexual health strategy should also set out a clear framework through which local areas will be assessed against the quality standards, with the findings made public both to ensure best practice is widely shared, and to increase public accountability. (Paragraph 61)


10.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. (Paragraph 79)

11.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. (Paragraph 85)

12.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. (Paragraph 89)

13.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. (Paragraph 90)

14.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. (Paragraph 95)

15.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. (Paragraph 100)


16.We welcome the Minister’s indication that prevention in sexual health will be a central part of the prevention Green Paper, and we expect the Government to set out in the response to this report how that commitment will be followed through into action, including the funding required to put it into practice. (Paragraph 108)

17.Prevention—activities that encourage healthy behaviours and changes that reduce the risk of poor sexual health outcomes—must be prioritised and adequately funded. Prevention is—or should be—an integral part of all sexual health provision, and the new national quality standards should therefore include preventative interventions within all aspects of sexual health. (Paragraph 117)

18.The Government must take a strong line on participation in Relationships and Sex Education (RSE). Public health arguments are overwhelmingly in favour of ensuring that all children have appropriate RSE. (Paragraph 119)

19.Furthermore, relationships and sex education should be

In its response to this report, the Government should indicate what steps it is taking to ensure that each of these recommendations is being implemented. (Paragraph 120)


20.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. (Paragraph 133)

Published: 2 June 2019