The following piece was written by Genevieve Kenrick in Spring 2024. All opinions expressed here do not necessarily represent that of Sexpression:UK
Acronyms
CBA – cost-benefit analysis
CCG / ICSs – clinical commissioning groups / integrated care systems
CM – contraceptive method
FSRH – Faculty of Sexual and Reproductive Healthcare
GP – general practitioner
IUD – intrauterine device
LA – local authority
NHS – National Health Service
OC – oral contraceptive
OTC – over the counter
PHE – Public Health England
PrEP – Pre-Exposure Prophylaxis (preventative drug to reduce chances of contracting HIV)
RCGP – Royal Collage of General Practitioners
RCOG – Royal College of Obstetricians and Gynaecologists
SRH – sexual and reproductive health
SRHC – sexual and reproductive healthcare
STI – sexually transmitted infection (not disease)
UK – United Kingdom
The State of Sexual and Reproductive Healthcare in the UK
Conceptual framework
SRHC is a “constellation of methods, techniques and services” that advance reproductive and sexual physical, mental, and social well-being, going beyond traditional confines of diagnosing and treating infirmity (United Nations Population Fund, 1994, pg. 30). Poor SRH leads to countless negative outcomes for the individual, wider society, and economy, such as lost work hours, unplanned pregnancies, psychological and physical distress. A three-pronged conceptual framework is used to group patients into the appropriate area for their concern – pregnancy (contraception, abortion), sexual health (sexual pleasure, FGM), and non-pregnancy (menopause, menstrual difficulties). This helps care providers understand and analyse the specific complexities of their unique needs.
The principle-agent model illustrates the UK’s tripartite SRH patient/caregiver/government relationships. The agent (care provider) is entrusted to perform a service (e.g. insert IUDs) on behalf of the principal (patient or government) due to an informational asymmetry, as government officials and patients lack necessary knowledge to diagnose and treat ailments. Herein lies an inherent tension, as raised by Klein (2004). This asymmetry allows actors to maximise their own needs of time expediency (NHS doctors repeatedly report being assigned too little time in primary care settings (Konrad et al., 2010), disproportionately affecting deprived areas more (Donaghy et al., 2024)) and cost efficacy (a reported “£14bn worth of efficiency savings have to be found by 2024-25” (O’Dowd, 2022)), at the expense of the principal’s medical needs.
Furthermore, GPs’ role in the NHS budgeting system is responsible for an emerging moral hazard (Smith et al., 1997). GPs can be delegated as ‘fundholders’ who purchase procedures through a budget bestowed upon them by the Department of Health. Surplus funding resulting from fewer procedures is retained for use within the surgery, incentivising them to misrepresent their principal’s welfare. This becomes a moral hazard when combined with the recent availability of over the counter (OTC) oral contraceptives (OCs) (10 Downing Street, 2023). Research shows contraceptive counselling from a doctor to counteract lack of accessible and accurate information is essential to continued effective use, whilst reducing side effects (Leeman, 2007). Continued conversations revisiting chosen CM as needs change is vital (Claringbold, Sanci and Temple-Smith, 2019) and inadequate counselling has sizeable impacts on quality of care (Wyatt et al., 2014). GPs are incentivised to avoid taking contraception consultations, instead exploiting information asymmetry by directing people to a pharmacist to collect OC, allowing their limited time to be spent on more financially valuable cases.
This model helps understand why certain regulatory practices are damaging. Healthcare providers act on behalf of two separate groups, the patient, and commissioner/regulator. Care Quality Commission (2018) points to this dual facing representation, with the patient as the secondary priority and the government actor as the primary ‘customer’ in healthcare, as the source of poor-quality care and outcomes. Healthcare providers then focus too much on external targets, such as total STI tests performed, and ignore the complex personal needs of the individual, especially sexual health, and pleasure.
Equity
Mann and Stephenson (2018) identified an overly negative focus on “morbidity outcomes” and broad quantitative population metrics within data collection.
This data then guides policy/regulatory creation, alteration, and evaluation which impacts provider behaviour, ultimately leaving minority groups’ complex needs ignored (Parkes et al., 2020, pg. 13). Focus on mortality and pregnancy leaves vast gaps in monitoring sexual health and wellbeing, with chronic issues ignored as they have complex assessment challenges with no significant, single monitoring or diagnostic metric (such as endometriosis’ 8 year diagnostic delay (Ghai et al., 2020)). Quality Adjusted Life Years (QALYs) assessments are an underutilised but promising tool in shifting focus to the impact of health interventions on lived experience.
Fathalla and Fathalla (2017) noted that natural health inequalities become equity issues when caused by societal and policy structure. The President of FSRH wrote that “women are falling through the cracks of a fragmented SRH system”, worsened by severe budget cuts to the healthcare sector (totalling £700 million in 5 years). These harsh cuts fell disproportionately on SRH (FSRH, 2020a) with 44% of local authorities reducing spend on SRH advice and 30% on contraceptive services (The King’s Fund, 2019). The health of the 8 million reproductive age women in lower socio-economic areas suffered the most (FSRH, 2020a). Given women are the majority users of SRH (89% of contacts (Statistics Team, NHS Digital, 2017, pg. 7)), poor provisions impact them more severely. They shoulder the health and risk burden of contraception, STIs, and poor wellbeing (FSRH, 2020a). Of the women surveyed in Mann, Davison, Logan, et al. (2018, pg. 21), 80% reported unwanted SRH symptoms interrupting daily activities. Furthermore, only 52% of women were found to be in ‘good sexual health’, compared to 83% of men (Parkes et al., 2020, pg. 6, 9). This study further identified a ‘highly vulnerable’ grouping amongst women surveyed, who were more likely to report condomless sex with low STI risk perception, and an assortment of SRH difficulties, and had higher reported instances of abortion and non-volitional / coercive sex (pg. 11).
Despite all this, the sector seems largely uninterested.
Sociology and psychology
Nudging is the manipulation of choice architecture to help individuals overcome their cognitive biases to achieve desired ends, by making the means easy, attractive, sociable, and timely. Studies have shown nudging is particularly effective at encouraging at risk groups to get tested regularly for HIV and STIs, through positively worded SMS reminders, with references to ‘protecting the community’ (Aung et al., 2022).
Previously, the patient and GP would discuss available CM options and finding the ‘right’ one was a sizeable undertaking, requiring diligence and attentiveness to unique circumstances (Field, 2020). Fiebag et al. (2015, pg. 2, 7) found that when doctors shouldered this cognitive burden, those with less SRH experience and/or more complex cases, they were “forced” to revert to OCs and failed to tailor to the patients’ specific needs. With new OTC OCs, this burden has been shifted even more onto women, as they are tasked with the responsibility to choose an appropriate CM, despite insufficient information and understanding of the subject. Mann, Davison, Logan, et al. (2018) found 50% of women receiving OC from a GP would rather receive them online or from a pharmacy. Women make a quality of life / ease trade-off by choosing potentially inappropriate OCs based on a limited understanding but are more convenient to acquire, to avoid the immense cognitive burden of a full and comprehensive search. This fear of, or resulting exhaustion from, cognitive burden has been shown to impair contraceptive efficacy (Field, 2020) and leads to dissatisfaction, misuse and non-use (Wyatt et al., 2014).
Production of knowledge
The UK’s SRH provision and quality is inadequate, in-part resulting from the fractured and inaccessible structure, guided by detached academics’ and regulators’ esoteric papers who ignore the intended care recipients (FSRH, 2023). Despite 30-60% of women stopping hormonal CM due to intolerable side effects, little is being done to improve their situation (Westhoff et al., 2007). Littlejohn (2013) suggests that researchers and healthcare providers have an overly medical approach to CMs, neglecting considerations of personal and social experience and perceptions. Wyatt et al .(2014, pg. 10) concurs, emphasising the importance of including intended users in the process of creating decision making tools, to include attributes that matter most to them. They also noted that the current research into these preferences was severely lacking.
In response to this, efforts in co-production have been undertaken by the NHS, to moderate success. Citizens, practitioners, and experts come together to devise patient centred policy. The Care Quality Commission (2018) report emphasises need for active involvement of multiple voices to conceive and develop policy. This shouldn’t be tokenistic. Ongoing active and productive engagement with the needs and expectations of patients is necessary. NHS England’s 5 values and 7 steps to co-production enshrined this idea (NHS England and Coalition for Personalised Care, 2021). Mann and Stephenson's (2018) diagnosis of SRH’s unmet needs led by example, by using a consensus process to consult “stakeholders representing all key groups”. Their document “What do women say?” polled 7500 women to gain deeper personal understanding of the issues facing the consumers of SRH, which would’ve been ignored if quantitative data alone was used. Lewis et al. (2023) agrees, highlighting the need to involve young people early in the SRH policy creation, as their specific needs have a “remarkable lack of attention”.
Following from this co-produced policy, one hopes, is improved health for the population, which in turn enables economic growth (Well, 2007), alongside the alleviation of intrinsically wrong inequality.
Regulation
Government regulation fails to deliver optimal standards of care with regards to inequality. The Equality Act (2010) provides comprehensive regulations preventing discrimination on the grounds of protected characteristics (including race, sexuality, and gender), in service of ending intrinsically unjust inequalities and advance social welfare. Despite this, pervasive inequalities disproportionately affecting these classifications exists throughout SRH, with 12% of those dying in the perinatal period having complex disadvantages, and black maternal deaths were four times the national average (Knight et al., 2023, pg. 16, 21). The current legislative framework, appears to be too focused on the more visible discrimination, rather than structural inequalities, like access to high quality maternal care in deprived areas (in which the relative risk of maternal death is three-fold (NHS England, 2021, pg. 6)).
Actors and institutions
To understand how policy is (or isn’t) made, understanding relevant actors and institutions is vital.
With legislative and fiscal powers, government agents are significant policy actors. Portfolio holders, such as Minister for Women and Equalities, are especially important as they advocate for, and guide change, inside and outside government. All-Party Parliamentary Groups (e.g. Women’s Health or SRH) provide these parliamentarians a less partisan space to examine issues and solutions.
Patients (981,000 in 2022-3 (NHS Digital, 2023)) are key actors, SRHC’s core purpose, and those ultimately navigating and engaging with services. The final significant group are healthcare providers. Whilst nurses take less time and money to train and still provide high quality SRH care and patient education, 34,709 nursing vacancies remain unfilled (Campbell, 2004) (British Medical Association, 2024). Of the UK’s 296,182 licensed doctors, 72,500 are ‘junior’, 66,000 GPs, and 85,700 specialists of which only 531 are GUM/HIV specialists (General Medical Council, 2023, pg. 21) (Royal College of Physicians, 2023). The NHS’ medical labour market monopsony results in stagnating salaries (26.1% real terms pay cut since 2008 for junior doctors (British Medical Association England, 2022)) and limited bargaining power, leaving them to strike, or increasingly, leave (General Medical Council, 2023, pg. 63). Resultingly, the UK has only 2.9 doctors per 1000 residents, compared to the OECD EU average of 3.7 (OECD, 2023), leading to reduced care quality.
GPs bridge the gap between actor and institution by commissioning and providing services directly. One study found 41% of GPs experienced increased contraceptive appointments, with many additionally struggling with an overly complex system without sufficient training (Stokes-Lampard, Thompson and Gracie, 2017, pg. 7, 9).
Following the Health and Social Care Act 2012, SRH service commissioning was restructured and fragmented through three institutions (Fothergill and Woolgar, 2022) (Stokes-Lampard, Thompson and Gracie, 2017, pg. 6-7). The first is the NHS, with a budget of £178.5 bn (Hunt and Huddleston, 2024, pg. 47), which provides numerous services (e.g. HIV treatment) through various outlets (e.g. sexual assault referral centres). The second are ICSs, where local multiple organisations come together to plan and pay for healthcare services (e.g. psycho-sexual healthcare).The third and final commissioner are LAs who do so under local public health contracts, largely in primary care settings (e.g. LARC provision in community SRH centres). They have experienced dire cuts to public health grants, limiting their efficacy (£1bn between 2015-2021 (Fothergill and Woolgar, 2022)).
Private sector corporate governance of these arrived under Thatcher, decentralising organisation and introducing clientelism (Ferlie and McGivern, 2014). Renaming patients to ‘consumers’ was intended to empower them to demand better service and shed the outdated medicine’s embedded paternalism (Bolton, 2002). Both SRH user and practitioner have expressed discomfort with this, favouring a return to ‘patient’ to respect the provider’s inherent emotional labour and the attendee’s vulnerable position (Loudon et al., 2012).
Policy making process
John Kingdon’s multiple streams framework for analysing the dynamic and tempestuous policy formulation process identifies three ‘streams’ which may align to open a window of opportunity – problem, policy, and politics (Kingdon, 1984, pg. 21). Practitioners are well acquainted with SRHC’s problems, with 9 representative bodies signing a statement declaring the system to be heading towards collapse (FSRH, 2020b). Further reports commend the massive advances in service provision, but clearly warn it will be undone without sufficient investment (Fothergill and Woolgar, 2022). Patients too know the strains, with surveys finding most struggle accessing care (Bermingham, 2019).
Thankfully, numerous solutions are readily available, including an integrated holistic commissioning service operating under a single body, with wide industry support (FSRH, 2020b). RCGP issued a report with seven England-wide and 3 UK-wide recommendations to respond to existing, specific, and complex issues (Stokes-Lampard, Thompson and Gracie, 2017).
The issue’s salience and proposed reforms fail to produce change as there’s no organised political force to shepherd them. The aforementioned fragmentation abdicated national government authority to LAs and supposedly allowed providers to tailor service provision to their region (Kneale, Rojas-García and Thomas, 2019, pg. 9). This provided ample room to ignore pleas to address sizeable quality imbalances, such as 15-17 year old conception rates ranging from 2.1 to 30.4 depending on LA (Fothergill and Woolgar, 2022)(Yilmaz and Willis, 2020). This devolution of responsibility combined nicely with the increased climate of austerity to further impede proper SRHC. LAs have struggled providing adequate care without commensurate budgets. Engagement with risky lending practices to cover costs has led to further government and public scrutiny and condemnation (Dagdeviren and Karwowski, 2022).
A window of opportunity is unlikely under this governing party, so long as they remain committed to austerity policy and state downsizing without sufficient pressure to weather the backlash. This can be seen in their refusal to act on any substantial recommendations from the comprehensive committee report in 2019 (Health and Social Care Committee, 2019), in favour of retaining the insolvent, disintegrated structure (Hancock, 2019).
Policy as politics
Public opinion is often decisive to the allocation of political, human, and economic capital.
Whilst awareness of SRH’s importance is higher, surveys demonstrate that the general public underestimate STI contraction risks (Clifton et al., 2018). As awareness rises there will be increased usage of the already strained system. However, the public will not feel it relevant enough to them to warrant placing sufficient pressure on policy makers to enhance the system.
Austerity measures often shift elements of social welfare onto the individual (“responsibilisation”) to ease financial burdens on governing bodies. Already stigmatised topics are especially at risk, as shortcomings are written off as ‘irresponsible behaviour’. Moral judgement too frequently leads in SRH policy making, see in the refusal to publicly fund PrEP likely in response to perceived public opposition to risky or ‘immoral’ sexual behaviour amongst a marginalised group being endorsed by the state. One paper tested this perception’s validity and found the public widely supporting state provision. They concluded that the mere potential of public outcry is enough to alter decision-making on SRH issues (Hildebrandt, Bode and Ng, 2020, pg. 643, 650-1). Evidence alone seems insufficient, as policy actors also draw upon perceptions (their own and others’) and act within a morally bound terrain.
Demand and supply of evidence
The supply chain of evidence essential to the SRH policy, is a highly political matter.
Government is the largest commissioner of evidence, largely through consultations and LAs. Consultations facilitate scrutiny by inviting the public to provide input on proposed and existing policy’s benefits, consequences, effects, and coherence. The most common methods, premade department issued surveys or calls for evidence (empirical or qualitative), suffer heavily from sampling bias, limiting the evidence’s external validity and policy’s potential efficacy, evidenced by the 2022 consultation on home abortion. Of 18,659 individual responses, 9,109 were campaign affiliated, 97% of which were anti-abortion, a number widely unrepresentative of the national mood (76% in favour (Clery, 2023, pg. 4)). 83% of those who reported taking the pills themselves, believed it to have a positive effect on safety (Department of Health and Social Care, 2022).
Devolution of public health to LAs has changed the type of evidence demanded, from information covering large swathes of people, towards geographically smaller data sets to enhance localised knowledge. In an environment of intense austerity policy and increased budgetary scrutiny, economic evidence is more heavily relied on than some may find ideal (Kneale, Rojas-García and Thomas, 2019, pg. 8).
Multiple prominent representative groups regularly provide this evidence, such as the FSRH, RCGP, and RCOP reports included throughout. Additionally, evidence collated by Natsal, a decennial survey of 10,000 people aged 16-59 to gage the UK’s sexual behaviour and patterns (Natsal, 2024), has been used to formulate several important government SRH policies, including the ‘National Chlamydia Screening Programme’, ‘HPV Vaccination Programme’, and ‘The Teenage Pregnancy Strategy (2000-2010)’. Natsal’s methodological plurality, i.e. using biological samples alongside face-to-face interviews and surveys, is a respectable effort to overcome concerns over the quantification of abstract wellbeing and value based data (Clifton et al., 2019, pg. 24). Their independence from governing bodies reduces the political factors involved in research design, which shape how and what evidence is collected, often to produce especially favourable results for certain political positions without glaringly obvious conflicts of interest.
Evaluating policy
Evaluating policy before and after implementation is essential, as it ensures the intended consequence is occurring with minimal wastage and negative externalities, and if not, the appropriate changes can be made. Weighing a policy’s anticipated benefits with foreseeable costs produces a calculus to help select the best of multiple mutually exclusive projects.
Considerations of immediate implementation costs are often prioritised over potential future reductions, as distant savings are often discounted in the face of present spending. The fact that the average cost of SRH consultations fell by 30% between 2013-20 is unlikely to be factored into deliberations ahead of time, leading to inaccurate analyses and flawed policy (Fothergill and Woolgar, 2022). Government guidance subsequently suggests discounting future financial values by 3.5% (Glover and Henderson, 2010, pg. 17).
Due to SRHC’s fragmented state, when one commissioner cuts services, they may not bear the costs directly. Instead, they’re transferred to other local service providers. One study estimates that every £1 cut from SRH, costs £86 overall (Stokes-Lampard, Thompson and Gracie, 2017, pg. 9). PHE’s CBA for state funded contraception produced similar results, demonstrating £9 of savings for every £1 invested, with £2215.5 million in spending for pregnancies, and later child rearing, averted (Public Health England, 2018). These diffused costs are difficult to factor into CBAs and subsequent policy often fails to account for the wider impact on other providers.
Externalities, such as the community benefits from the increasing number of child exploitation and domestic violence cases picked up on by SRH services (Fothergill and Woolgar, 2022), are difficult to factor into CBAs and present real challenges to the applicability and efficacy of policy evaluation.
It’s especially important to note that SRH has substantial emotional value, varying in weighting between individuals, and cannot be conveniently converted into metrics. This opens space for politically motivated judgements determining the appropriate gravity of factors.
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