The health and social care select committee has launched an inquiry into sexual health. The move comes as serious infections are rising and funding is falling, hitting services of vital importance to young people and many others.
Demand for services has been rising relentlessly. Between 2013 and 2017, total attendances at sexual health services in England rose 13% to more than 3.3 million. New diagnoses for gonorrhoea increased 66% between 2012 and 2017, while syphilis jumped 136%. Chlamydia infections fell by 3.5%, but infections are still diagnosed in more than 200,000 people each year. Chlamydia testing has been falling, while drug resistant strains of gonorrhoea have emerged.
The news on HIV is more encouraging, with Public Health England reporting a UK-wide 18% decline in diagnoses between 2015 and 2016. The power of good sexual health services was underlined by a 29% decrease in London, with the largest declines seen in boroughs with the highest testing rates and prompt access to treatment.
According to the select committee, the impact of sexually transmitted infections remains greatest in heterosexuals aged 15 to 24 years, black ethnic minorities and gay, bisexual and other men who have sex with men.
Responsibility for commissioning and funding sexual health services largely moved from the health service to local government, along with many other public health services, under the 2013 NHS reforms. They cost around £600m a year.
King’s Fund analysis reveals that since then, councils’ like-for-like real terms spending on public health has fallen from £2.6bn to £2.5bn. Further real terms cuts averaging around 3.9% each year are expected until 2020-21.
In 2017-18 sexual health promotion, prevention and advice services suffered by far the biggest cut – around a third. National spending on contraception and STI testing and treatment was similar to the previous year, but that disguised significant cuts in many local areas.
The arrangements for commissioning and providing sexual health services are messy, and none more so than for HIV. Local authorities are responsible for commissioning prevention work, as well as testing in the home, sexual health clinics and primary care. NHS England is responsible for commissioning HIV treatment. Clinical commissioning groups are responsible for commissioning testing in hospitals, while sharing commissioning for primary care services with NHS England and HIV support services with local authorities.
While research by the King’s Fund and others indicates that people with HIV are generally satisfied with the quality of clinical care they receive, the unnecessary complexity of the way the full range of HIV-related services are commissioned and delivered undermines effectiveness and integration. Across sexual health services, blurred accountability is inhibiting action.
Like every other area of local government spending, councils are now cutting core sexual health services to balance their budgets. Clinics are being closed, restricting access to services. This would matter for any branch of healthcare, but sexual health services are particularly dependent on easy access to encourage people to attend. Access to emergency contraception is being undermined.
From 2020, the government plans to fund public health through locally retained business rates. As the British Association for Sexual Health and HIV has told the health secretary, this risks compounding health inequalities in deprived areas.
There is a widespread feeling among public health staff that the NHS no longer sees public health as its problem. The mantra is supposed to be “make every contact count” when it comes to prevention and health promotion, but there is little evidence of a united effort on sexual health across local government, primary care and hospitals.
Moving sexual health services to local government was a good idea. It encourages the embedding of those services in their communities and offers the prospect of better support for groups that can be hard for the NHS to reach, such as young people. But the relentless cuts to local government funding are putting people’s physical and mental health at risk, while the blurred accountability is undermining the importance of sexual health as a political priority.