Sexual health services: a cut too far?
Due to pressure on local government to cut spending, HIV drugs have fallen into a commissioning gap and contraception advice is failing. And there are more cuts to come
The pressure to do more with less to meet the needs of an ageing population with more complex health needs is leading to difficult decisions about which services to cut. Sexual health has not escaped – and is beginning to suffer because of the financial constraints on the NHS and the wider public sector.
Public health funding will see a 9.7% reduction between 2016-17 and 2020-21 – equivalent to a loss of £330 million, according to the Local Government Association (LGA). This is on top of the £200 million cut for 2015-16. Such cuts have been affecting sexual health service provision since responsibility was shifted to local authorities three years ago.
RCN professional lead for public health nursing Helen Donovan says: ‘Local authorities are even more hard pressed for money so there’s an even bigger drive for cost savings.
‘The picture for sexual health services is very mixed across the country. The drive seems to be around the integration of services and creating a single point of access for people.
'The wider concern for us is to make sure that people who are particularly vulnerable, such as teenagers and young girls who are victims of trafficking, access a service that is not too generic to get the care they need.’
She adds that due to the realignment and merger of services within the NHS and sexual health provision, there has been ‘nervousness’ about recruiting nurses to post and investing in training.
She fears some patients fail to get access to suitably skilled healthcare professionals or do not receive high quality assessment of their health needs.
‘The big risk comes in making sure that vulnerable groups have access to highly qualified staff,’ she says.
School nursing squeezed
Queen’s Nursing Institute (QNI) chief executive Crystal Oldman explains that her biggest concern is that local authority cuts could mean a reduction in preventive sexual health services. Queen’s nurses report that resources are being squeezed in school nursing and health visiting, despite government investment in recruiting more nurses.
Latest Health and Social Care Information Centre statistics show that in February there were 1,078 whole-time equivalent (WTE) school nurses. This compares with 1,140 in September 2011.
Dr Oldman explains that some local authorities are cutting back on school nursing provision while others no longer require any service whatsoever. ‘Children and young people at school are not getting access to the kind of advice they might have done previously,’ she says.
‘There is a lot of work that’s done by school nurses in terms of sexual health education and also drop-in confidential health sessions, so there is a question about where the children and young people are going to go
She fears that any potential cuts to health visiting and family nurse partnerships could also mean less advice for teenagers in preventing future unplanned pregnancies. The UK already has among the highest rates of teenage pregnancies in Western Europe (see Fast facts).
This month, the National Institute for Health and Care Excellence is expected to publish guidelines on contraceptive services. The draft quality standard outlined 12 recommendations, improving school and education-based contraceptive services, outlining the need to ensure accurate and up-to-date contraceptive advice, information and support.
The consultation document says that an estimated 30% of pregnancies are unplanned.
‘The guidance will be a good lever and provide something to present to local authorities when bidding for services in the local area,’ says Dr Oldman.
Queen’s nurse Jo France, who works as a school manager and professional lead across Shropshire in her substantive role, says school nurses are increasingly finding it difficult to provide the full range of sexual health services because of ‘competing demands’. There is also an expectation to focus on safeguarding, sexual exploitation and preventing ill health.
‘It is a struggle to put in that preventive work because there is so much safeguarding to do. At the moment our focus on sexual health services is reactive rather than proactive,’ she explains.
Sexual health charity Terrence Higgins Trust (THT) fears that support services for people living with HIV will be hit hard by budgetary cuts, particularly in south London.
‘There’s a worrying trend around HIV at the moment. It seems to be the area of sexual health being cut the most,’ says THT director of clinical services Liz Porter. ‘Where do people with HIV go for support? At the end of the day it is a chronic disease and these people still need support.’
'A missed opportunity to save lives'
NHS England has confirmed it will not fund new HIV treatment called pre-exposure prophylaxis (PrEP).
PrEP uses anti-retroviral drugs to stop viral transmission. NHS England stated that it cannot commission PrEP, adding that local authorities are now responsible for HIV prevention.
However, a Local Government Association spokesperson says NHS England retained commissioning of HIV therapeutics, which PrEP treatment ‘clearly falls into’.
‘This is hugely disappointing and a missed opportunity to launch a groundbreaking method of treatment which could halt the spread of HIV and potentially save lives,’ he says.
Terrence Higgins Trust chief executive Ian Green says NHS England’s decision is ‘shameful’. He adds that if taken correctly, the treatment ‘is almost 100% effective in preventing HIV’ and is already available in America, Canada, France and Kenya.
Rise in abortions for over thirties hints at failures in contraception services
Abortion rates have increased among women aged 30 and over, as well as those who are in relationships or who are already mothers, statistics show.
Department of Health figures show that overall the abortion rate in England and Wales is stable. While abortion rates have fallen among all age groups under 30 since 2005, an increasing proportion of those having terminations were over 30 or in a relationship.
Since 2005, the rates for women aged 30 to 34 have gone up from 14.5 per 1,000 women in 2005 to 17.1 in 2015, and rates for women aged 35 or over have gone up from 6.8 per 1,000 women in 2005 to 7.8 in 2015.
Barriers to contraceptive services and misleading warnings about declining fertility after a certain age may contribute to increasing abortion rates among older women, according to the British Pregnancy Advisory Service (BPAS).
There are concerns that older women find it difficult to access contraception, with some services restricted to younger women, such as free emergency contraception.
BPAS chief executive Ann Furedi says: ‘We need to ensure women have access to good evidence-based information on fertility that gives them the knowledge they need to make the reproductive decisions that are right for them across their lifetimes.’