On Monday 11 February 2019 the Health and Social Care Committee visited Plymouth in connection with their inquiry into sexual health. During the morning the Committee visited sexual health services in Plymouth and heard specifically about the Plymouth experience.
In the afternoon, the Committee invited a wide range of people involved in delivering and commissioning frontline sexual health services. Patient representatives were also invited. The attendees came from a variety of professional backgrounds, and travelled from eleven different areas of the country.
The Committee is extremely grateful to all those who attended for their frank, positive and expert contributions. In particular the Committee would like to express sincere thanks to the many attendees who travelled long distances to attend the event. We are also indebted to Plymouth City Council for providing the venue and giving assistance with the practical arrangements.
Kate Horne, Senior Programme Manager, Calderdale Council
Dr Emily Hosfield, General Practitioner, Birmingham
Sarah Aston, Advanced Public Health Practitioner, Torbay Council
Dr Michael Brady, London Sexual Health Providers Group
Dr Lisa Haddon, consultant in sexual health, Royal Cornwall Hospital
Paul Jamieson, Lead Officer Public Health, Wigan Council
Yasmin Dunkley Prevention and Testing Manager, Positive East, London
Natalie Slayman-Broom, Business Manager, Umbrella Integrated Sexual Health Services, Birmingham
Mike Passfield, Head of Integrated Contraception & Sexual Health (iCaSH), Cambridgeshire
Mary Hague, Public Health Lead, Sexual and Reproductive Health, Derbyshire County Council
Dr Amy Evans, Lead Clinician and Consultant in Genitourinary Medicine and HIV, Leeds Teaching Hospitals Trust
Rebecca Spencer: General Manager, Integrated Sexual Health Services, Derbyshire Community Health Services NHS Foundation Trust
Dr Gillian Holdsworth, Director, SH:24
Liz Sawyer, patient representative, Healthwatch Surrey
Derval Harte, Consultant in Sexual Health and HIV Medicine, Plymouth University Hospitals NHS Trust
Laura Juett, Senior Public Health Specialist, Plymouth City Council
Dr Sarah Wollaston (Chair); Rt Hon Ben Bradshaw; Diana Johnson; Johnny Mercer; Dr Paul Williams.
Laura Daniels, Senior Committee Specialist; Dr Joe Freer, Clinical Fellow; Victoria Pope, Inquiry Manager.
Services were described by some as being in ‘crisis’ and at ‘breaking point’. It was felt that there were no areas left in which further efficiencies could be made—services identified as ‘low hanging fruit’ had already been cut.
The emergence of AMR in gonorrhoea and increases in syphilis—with some areas reporting that rates of syphilis had tripled—were described.
Inequities were described in the provision and availability of many aspects of sexual health services, meaning that these were available in some areas but not in others. These included:
On PrEP, attendees described “huge issues with the IMPACT trial—geographical inequities in access, north/ south divide, depending on what kind of contract you have, depending on all sorts of commissioning and provider arrangements”—this was described as “a microcosmic representation” of the fragmentation and variability that besets all aspects of sexual health provision.
On access to different methods of contraception, including LARC, attendees reported a number of issues relating to primary care provision. It was seen to be hard for smaller practices to get enough experience; lots of GPs with fitting experience were retiring; and this was not seen as a priority by many practices. Economic analysis by one local authority suggested that not enough funding was attached to provision of LARC. One area reported that while some 2/3 of GP practices offered LARC fitting, patient experience was often poor. An innovative networked service model was reported in one area whereby patients can access services at any participating practice.
Attendees reported the success of pharmacy provision of emergency hormonal contraception; this has been extended in one area to including chlamydia testing and treatment, hep B vaccination, starting oral contraception.
Online sexual health services were discussed by many attendees, with a digital offer promoting self-care and self-management. This was seen to be positive in freeing up clinical services, but only for a specific cohort, mainly people already in contact with sexual health services. There were many people for whom such services would not be suitable, and there was general agreement that it should not be viewed as a ‘silver bullet. More generally, there was also a view that sexual health services could do more to increase their digital profile and online visibility.
Major concerns were reported by many attendees about the fact that outreach services for vulnerable populations has been ‘stripped back’. This includes work with asylum seekers, work done in conjunction with food banks, and efforts to target children in foster care and care leavers, although some areas reported ongoing outreach work targeting public sex environments. On the whole there was felt to be “lots of unmet need in communities who are at risk, because they are not part of the clinic population, and are therefore slipping through the net.
On a similar note, attendees were supportive of attempts to improve RSE but felt that unless these were properly financed they wouldn’t work—busy services can’t spare clinicians to contribute.
Working in sexual health was seen as insecure, and staff reported feeling uncertain about the future of sexual health services
Training was raised as a concern—both of GPs and sexual health specialists. Queries were raised about how training was funded and funding levels, as well as uncertainty about roles and responsibilities, in particular role of HEE.
Attendees argued strongly that “the clinical workforce needs to feel parity with the NHS workforce, it is no longer competitive and seen as insecure”.
Attendees described a strong “sense of injustice that, unlike the NHS budget, local government public health spending was ‘an easy target’ for cuts.” One attendee reported cuts of up to 18% of their local sexual health budget.
Cuts were seen to be “affecting the ability to focus on anything beyond the bare minimum.” In particular, as detailed above, attendees described how funding for prevention, wider supportive services, and outreach for vulnerable groups, has been ‘stripped back’.
This was widely seen to be a false economy - reduced HIV prevention will lead to increased HIV cases which will incur a high cost which will be borne by NHS.
Attendees described the difficulty sexual health has competing for funding against other council provisions, like bin collections and libraries. Some local authority representatives felt that their Cabinet did not understand the importance of health promotion and education; and also that it could be hard to gain support for focusing on marginalised groups with high levels of sexual health need like MSM and sex workers.
Attendees told us it was possible to successfully design and implement integrated and collaborative approaches to commissioning, including lead provider consortium models. Further details on these approaches can be found in the written evidence submitted by attendees.
However this was not always possible. Some attendees argued that collaborative working was ‘easier said than done’ and that behavioural change and culture change are challenging to deliver. A particularly difficult issue was the funding of cervical screening as ‘funding pots are split so resolutely’,
Cross charging was identified by many attendees as a significant difficulty. Guidance was described as ‘completely inadequate’; some local authorities refuse to be cross charged, leaving cost pressures of up to £250,000; in London 31 boroughs worked collaboratively on this, but can’t recoup funds from residents who are out of London, who often travel to London from areas which have had their services cut. There is a significant administrative burden, with ‘people employed on both sides solely to manage this issue’. When asked if ICS might help, the response was that ‘possibly’ they would, but there are issues around lack of coterminosity.
There were many criticisms of the tendering process, particularly the repetitive, short term nature of the process, which has to be repeated frequently in many areas. Attendees were strongly in favour of longer contracts, up to eight or ten years, but many were having to work within much shorter contracting arrangements. Short term contracts also inhibit long term service planning and in the words of one attendee, ‘bind our hands’.
While attendees felt it was reasonable to expect services to be delivered cost effectively, some argued that competitive tendering can have a destabilising effect as competition has stifled the ability for providers to develop collaborative networks and relationships. The negative impact of competition on innovation was also raised: “sexual health services are not a group who are afraid to innovate, but difficult to innovate when competing”.
In terms of what type of organisation provides care, some attendees reported poor experiences with private providers and felt services should be NHS provided, but others thought it did not matter, or that it depended on the service that was being provided.
The groups also discussed the location of sexual health within local authorities’ public health function, and whether it should move back to the NHS. A few attendees thought it should as might be better funded. Public health was seen to be an easier target for cuts than standard NHS services. However some attendees felt that there had been lots of learning through the relocation of public health to local authorities, especially around VFM, and that the prevention agenda has been strengthened since PCT days.
Attendees also felt that there were real benefits of commissioning sitting with local authorities—for example integration with education. A recent example was given of vaccinating foreign sex workers against measles. However some felt these advantages were not being properly utilised. Some reported local authorities spending money badged for public health on other things as they have so many competing priorities. Conversely, other attendees gave examples of local authorities shifting resources towards prevention, but consequently leaving gaps in service provision.
One attendee suggested that local authorities should retain the benefits of the savings they are making e.g. £450m saved by HIV prevention.
Many attendees felt that it did not matter where money and commissioning were located, as long as the money was there.
Published: 2 June 2019