The following piece was written by Genevieve Kenrick in Spring 2024. All opinions expressed here do not necessarily represent that of Sexpression:UK
Acronyms
BASHH – British Association for Sexual Health & HIV
CCG – clinical commissioning group
FSRH – Faculty of Sexual and Reproductive Healthcare
ICS – integrated care system
LA – local authority
LARC – long-acting reversible contraception
NHS – national health service
OC – oral contraceptive
PHG – Public Health Grant
RCGP – Royal Collage of General Practitioners
RSE – relationship and sex education
SAS doctor – specialist, associate specialist and specialty doctors
SRH(C) – sexual and reproductive health (care)
STI – sexually transmitted infection
A Policy Brief on the State of Sexual and Reproductive Healthcare in England
England’s state provided SRHC system teeters on the brink of collapse, affecting millions’ wellbeing as vital services are cut. SRHC is a broad term, covering numerous programs, departments, and services (e.g. STI prevention, testing and treatment; contraception provision; abortion care; and reproductive advice (FSRH, 2020b)) provided in varying proportions by LAs and/or the NHS. Its role is ensuring people’s mental and physical health, with respect to their reproductive systems, sexuality, and autonomy. With its 981,000 annual service users (NHS England, 2023b) and wider role in population control, SRH affects everyone (with varied intensity depending on gender, location, and socio-economic status) and has important economic ramifications. Urgent action to reverse more than £200 million worth of cuts and rapidly invest in public health is desperately needed to prevent further damage to communities. This investment should take two forms – ring-fenced funds within the public health grants, and workforce enhancement grants. Increasing the newly formed ISCs’ resources will allow them to successfully minimise adverse effects of fragmentation and halt the staffing succession crisis, resulting in the quality and quantity of care, and wider public health, improving.
The Issue
Access issues blight contraception services, STI diagnoses are rapidly increasing, unintended pregnancies remain too common, and staff training and retention levels are plummeting. This is especially worrying when faced with a growing population with changing needs.
Whilst there was an 11% increase in contraception-related contacts in 2022 (NHS England, 2023b), total LARC prescriptions decreased sizeably and users repeatedly complain of inconvenient or non-existent times and location of appointments (Bermingham, 2019)(Office for Health Improvement and Disparities, 2024b). At 18.6 per 1,0000, Abortion rates are at their highest since legalisation, especially in repeat occurrences with women over 25, and strongly indicates contraceptive provision and education failures (Office for Health Improvement and Disparities, 2024c, 2024a).
Similarly, worrying patterns have emerged in under-18 conception. Whilst at the lowest level since 1969, rates nationally vary from 2.1 to 30.4 per 1,000 conceptions, indicating dangerously divergent localised strategies (Health and Social Care Committee, 2019b; Fothergill and Woolgar, 2022). Reliable contraception provides women autonomy over a serious medical event with potentially fatal implications, allowing them to live a fulfilling life and participate in the workforce. The government’s inadequate support of this process is a violation of human dignity.
STI prevalence is rapidly rising, and the strained test, trace, and treatment system is struggling to keep up. Whilst an increase in positive tests isn’t inherently bad, without a commensurate rise in the number of tests performed it becomes concerning – as seen in the Health Security Agency’s recent data demonstrating a 13.4% testing and 23.8% positive diagnosis increase from 2021 to 2022 (UK Health Security Agency, 2023). Specifically, Gonorrhoea cases rose by 50.3% to 82,592, and chlamydia by 24.3% to 199,233 (ibid.), and 10 localities saw rates triple (Local Government Association, 2024). An outbreak of anti-biotic resistant gonorrhoea saw 118 cases in England 2014-2018, and the lack of cases with direct connecting links left scientists concerned of a “considerable reservoir of undiagnosed infection fuelling transmission” (Smolarchuk et al., 2018, pg. 3). Incorrect or repeated antibiotic usage is often highlighted as a primary trigger (Unemo and Shafer, 2011). With such a strained system, and long wait times for an appointment, the risk of these strains emerging surges, as clinicians are unable to spend sufficient time treating and following up with each case. Despite the serious threat STIs pose to mental and physical health, the public grossly underestimates their risk, likely because 90% of cases are asymptomatic (Dudareva-Vizule et al., 2014; Clifton et al., 2018). Worryingly, the Terrence Higgins Trust’s investigation found only 51% of clinics would offer an asymptomatic patient an appointment. Even then, they had 13-19 day waiting periods. The national target is 48 hours. The last time monitoring was undertaken in 2011, 89% met this goal (Angell, 2023). Unsurprisingly, there’s been a considerable increase in hospital admissions for an STI since 2015, with syphilis and chlamydia-related cases doubling and gonorrhoea-related tripling (Goodier, Aguilar García and Vinter, 2024).
Aside from obvious health issues, a staffing crisis poses a considerable threat to SRH. A BASHH survey reported 63% of providers turning patients away due to capacity issues and 65% struggling with recruitment (BASHH and BHIVA, 2019). This is especially unsurprising when confronted with the unfilled 34,700 nursing vacancies, 10.2% of total posts (British Medical Association, 2024), and the 40% increase in SAS doctors, who act as senior medics in consultant deserts, leaving annually (General Medical Council, 2023, pg. 63). The NHS workforce plan conservatively estimates a shortfall of 360,000 staff by 2036 (NHS England, 2023a, pg. 17). A succession crisis is well underway, as the supply of clinicians qualified to train others rapidly depletes and the negative reinforcement cycle prevents replenishment, and remaining clinicians lack time and funding needed to train others. These staffing deficiencies increase strain and psychological burdens and have furthered the wider morale crisis (itself a deterrent to prospective specialists) and severely limits their ability to provide the care patients deserve (BASHH and BHIVA, 2019; Bermingham, 2019; Health and Social Care Committee, 2019a; Royal College of Nursing, 2019). This is only worsened when combined with junior doctors’ 26.1% real-time pay cut in the last decade (FSRH, 2020a; British Medical Association England, 2022).
There needs to be rapid action to increase access to appropriate contraception to bring down the abortion and STI rates, as well as investment in the workforce before it is too late.
The Cause
A decade of fierce austerity measures, deep fragmentation, and persistent stigma have created a profoundly broken system barely managing to operate at all, let alone achieve increasingly ambitions targets. Many don’t have the knowledge, time, nor incentive to continue to navigate this.
As attitudes have liberalised, people’s lifetime number of sexual partners has doubled, aided recently by the digitisation of socialisation. This expansion, and change in the geo-spatial nature, of sexual networks has posed challenges to transmission tracing and safe sex efforts, with 47% of young people reportedly forgoing condoms with new sexual partners, increasing chances of STI transmission (Health and Social Care Committee, 2019b, pg. 32) (Mercer et al., 2013). Despite these changes, SRH remains heavily stigmatised (Cook, Dickens and Fathalla, 2003, pg. 3)(Chollier, Tomkinson and Philibert, 2016).
‘Public health’ covers any health matters which affect groups differently, have causes larger than the individual, and/or require collective action from LAs and healthcare professionals (Ethics, prevention, and public health, 2007, pg. 14). Neither of these are homogenous entities – with 317 LAs, 229 trusts, and 6,925 GP practices in England (A-Z of councils online, 2024) (NHS in numbers today, 2023). This produces a fundamentally complex system. In the largest reorganisation since 1948, the ‘Health and Social Care Act 2012’ stripped public health from the NHS and placed it under LAs’ authority, funded by the PHG, though many practical matters were still the NHS’ responsibility (The Health and Social Care Act, 2012). Voluntary partnerships (CCGs) were encouraged to share service commissioning and provision responsibility, though liability remained with the original body tasked with commissioning, irrespective of who provided the service. The ‘Health and Care Act 2022’ attempted to rectify this fragmentation’s consequences, replacing CCGs with 42 statutory ICSs that brought LAs, NHS bodies, and third-party stakeholders together with shared liability and no competitive requirements (Integrated sexual health service specification, 2023, pg. 3). Nevertheless, patients are still unable to locate and receive care, staff culture is untenable, and ministerial accountability lines have been severed, allowing the problem to worsen.
Since David Nicholson’s 2010 challenge to the NHS to find £20 billion in “efficiency savings” by 2015, SRH has been extensively deprived of funding (Health and Social Care Committee, 2010). The PHG has been cut in real terms by £880 million in eight years (Local Government Association, 2024), leaving LAs to eliminate programs to save money. These locally elected bodies are largely responsible for preventative measures and so the negative effects of cutting them were passed on to discontinuous and distinct entities responsible for treatment, who had shoulder rising STI cases and unplanned pregnancies, with no commensurate increase in resources. In real terms, English LA spend on SRH services has dropped by £168,095,190 in five years (Eshalomi and Leadsom, 2024), with prevention services spending down 44%, STI test and treat 33%, and contraception 30% since 2013 (Goodier, Aguilar García and Vinter, 2024). Some have experienced cuts as high as 68% (ibid.). Modernisation efforts, coupled with the population’s growing needs, are incompatible with these ruthless downsizing efforts.
Overall, any solution, or action, to improve this state-of-affairs must work within the independent and uniquely complex systems and operating procedures of LAs and the NHS.
The Solutions
The FSRH have called for ‘women’s health’ to be formally reintegrated into the wider NHS (FSRH, 2020b, 2021b). Whilst the newly introduced women’s health hubs’ patient, not commissioner, centred approach is necessary, this wider policy would have hugely detrimental effects (Atkins and Caulfield, 2024). ‘Women’s health’ is inseparable from SRH as too many services overlap – contraception, ante- and post-natal, menopause, menstrual care – and integrating these back into the NHS would wreak havoc in an already disjointed system. On the other hand, these hubs shouldn’t be expanded to encompass sexual health as a whole, because that would dampen the much needed focus on women (FSRH, 2020b). Furthermore, this wouldn’t deal with the absolute lack of funding for any of these services.
The RCGP and Royal Collage of Nursing have both touted mandatory SRH training for GPs, medical students, and nurses as a viable solution to fix the crisis (Stokes-Lampard, Thompson and Gracie, 2017, pg. 5) (Royal College of Nursing, 2019). Whilst, again, necessary, this overlooks fundamental flaws in the system, such as the service fragmentation, lack of practitioners to train the surge in students, and lack of money.
The most common ‘miracle cure’, proposed by the majority of stakeholders, is an entirely new and holistic system of commissioning with “one body maintaining oversight and accountability” for all decisions (FSRH, 2020b). Theoretically, this would be the ideal solution. However, it’s too problematic to be successful now.
The recent reforms need to be given time to settle before they can be deemed a success or not. Any further sweeping government action would disrupt a system on the brink of collapse and be “counterproductive to service delivery” (Health and Social Care Committee, 2019b, pg. 19).
Policy ensuring adequate and appropriate funding is essential to fix this crisis. Instead of radical restructuring, we must support recent reforms to ensure it succeeds. A Nuffield Trust report highlighted the necessary elements for successful integrated care systems – “sufficient resources, incentives, regulatory and outcomes frameworks – and consistent leadership and cultures” (Reed et al., 2021a, pg. 3). Given a framework has been produced (Integrated sexual health service specification, 2023), and leadership and culture are difficult to legislate for, fixing the resource and incentive supply is the best option available. These should be delivered through two mechanisms – ring fenced funding within the PHGs, and workforce enhancement funding.
The annual PHGs are SRH ICSs primary source of funding, with this year’s amount totally £3.6bn (Department of Health and Social Care, 2024), of which SRH will account approx. 10% (Local Government Association, 2022, pg. 2). To prevent continued disproportionate defunding, the grant needs to be increased and SRH funds need to be ring-fenced to ensure a minimum spend. One report estimates that restoring SRH funding to 2013 levels would cost £285,335,680 (Ministry of Housing, Communities, and Local Government, 2015) though further increases might be necessary to repair the damage done. Just as each ICS’s grant is determined individually by the Advisory Committee on Resource Allocation (ACRA), so shall the ring-fenced amount (ibid.), to ensure each locality receives enough meet their unique needs (taking numerous factors into account – current service usage; MSM, youth, and BAME population; and STI rates and trends).
This policy’s second provision is the introduction of workplace enhancement grants. Additional funding must be made available on demand for ICSs to subsidise further training, incentivise new hires, and reward existing staff. Cash-strapped LAs fund 50% of Community SRH speciality training (FSRH, 2021a), so increasing this would allow more to be trained. Per person, it’s relatively cheap, with the highest qualification, the two year diploma course costing £435-£1,285 per person, and letters of competence for subdermal implant insertion and IUD techniques taking only 12 hours and is £550 per applicant (FSRH, 2024). Increasing the number of providers trained to perform these help doctors already burdened with running clinics, attending to complex cases, issuing prescriptions, and training others. Subsidising LARC, the most cost-efficient contraception, insertion training would be especially beneficial as if just 5% of OC pill users switch to LARCs, there would be an estimated £14.915 million in savings (Mavranezouli on behalf of the LARC Guideline Development Group, 2008, pg. 1342). Physicians associates currently fitting LARCs, performing hysteroscopies, and biopsies are a scaled trial of this additional care avenue as they cost £6.55 less per consultation, and have much shorter training periods, than GPs (Drennan et al., 2015, pg. 349). Increasing pay slightly for associate grade specialists whilst they either train to become, or fill the place of, a consultant could incentivise more to enter the sector and undo the chaotic image of the speciality (FSRH, 2020a).
To start, this would only be implemented in England, as health policy is devolved to the other nations, who also have unique commissioning systems. By following Perry’s five steps, implementation should be more effective –“combine designated and distributed leadership, establish feedback loops, attend to history, engage physicians, and involve patients and families” (Perry et al., 2022, pg. 2829)
These “feedback loops” would replace historic ‘P45 targets’, which saw high redundancies as unnuanced, single measure targets failed to be met (Reed et al., 2021a, pg. 63). Instead, performance should be appraised using a ‘basket of measures’ including under 18s conceptions, chlamydia detection rate, new STI diagnoses, LARC prescriptions, late-stage HIV presentations alongside other contextually specific indicators and patient experience, to not encourage neglect in favour of numbers and allow for increased funding where appropriate. A strengths and learning-based approach encouraging constant self-evaluation and adjustment, and the use of the Spend and Outcome Tool to track other ICSs outcome/spend, should be promoted and ‘delinquent’ ICSs shouldn’t be punished. Rather, they will receive flexible peer-based support, bespoke mandated support, or mandated intensive support through the recovery support programme, in-line with current policy (Department of Health and Social Care, 2022).
As highlighted by the Nuffield Trust report, cooperative culture within care systems is imperative to successful integration, the lack of which trigger the 2022 statutory reforms (Reed et al., 2021a, pg. 2, 4, 47, 65). Unfortunately, this cannot readily be legislated. The recent accountability reform corrected a previous flaw which potentially saw one body held liable for their partner body’s performance. This policy’s provisions aim to change workplace culture to enhance partnerships by proxy, by increasing funding for services and staff. Tensions over funding inequalities between health and social care providers, and feelings of burn out, will hopefully ease, as capacity increases and the cognitive burden of financial and under-staffing concerns reduces.
The government response to the 2019 Select Committee report indicated a concern that increased funding and mandatory minimum spend, would provide councils perverse incentives to squander resource (Hancock, 2019, pg. 8). This legitimate concern is misguided and would likely only occur if they’re given vastly greater than needed. Presented here is a relatively conservative approximation of what is needed, not wanted, for SRH to provide an acceptable, not optimal, level of care. Ring-fencing it ensures it’s not unduly carved into by other services’ budgets. A more realistic concern would be ICSs not assigning any further funding than the minimum. ICS, not single body, level monitoring would help prevent this happening.
The final, and most frequent, complaint is that the policy is too expensive.
Simply put, it is not. Sweeping cuts to SRHC creates a false economy where an impression of successful saving is made, only to encounter ballooning costs further down the line. Funding SRH is an investment. For example, every £1 spent on contraception is £9 saved for the government (Public Health England, 2018), every £1 cut from SRHC costs £86, and by 2020 these added up to £8.295 billion extra and 73,000 additional STI diagnoses (Family Planning Association, 2015). With 7.65 million contraception users (NHS Digital, 2022), and 2.196 million sexual health screenings (UK Health Security Agency, 2023), this sector cannot be deemed a fringe interest. Whilst large spending increase is daunting and politically risky, it’s undeniably the right thing to prevent imminent and total system collapse.
Feasibility
Both LAs and SRHC representative bodies are intimately aware of the sector’s issues, issuing multiple reports and statements openly calling for a reverse to cuts and an increase in the PHG (British Association for Sexual Health and HIV, 2024) (FSRH, 2021b)(Lowbury, 2019; Fothergill and Woolgar, 2022; Local Government Association, 2024). However, LAs are struggling with communicating this effectively to national legislative bodies and have no power to enforce their will, an inherent weakness of devolution. Whilst the public may be aware of the challenges to access or service from personal experience, the topic is generally absent from public debate, likely due to ongoing stigma. These both make change harder.
Fear of backlash can guide policy decisions and lead to disproportionate cuts to controversial sectors, even when the disapproval is imagined (Hildebrandt, Bode and Ng, 2020, pg. 651). Whilst there’s little research into contraception’s public standing, it appears there’s a belief that access to RSE and contraception increase promiscuity, despite research repeatedly showing otherwise (Dreweke, 2019). Making this more widely known, as well as researching public perception, would help combat lingering apprehension or opposition. Additionally, LAs have experienced a 10% drop in trust in the last two years (Clemence, King and Skinner, 2022, pg. 6), likely due to growing dissatisfaction with public service resulting from spending cuts (Page, 2017), and a worrying increase in section 114 council ‘bankruptcies’ since 2018 (Stride, 2024).
With the General Election, and predicted Labour victory, looming, it’s worth considering what this means for this policy (Electoral Calculus, 2024). The Conservative Government are responsible for the cuts and have rejected most proposed solutions, notably reintegration and funding increases as suggested by the 2019 select committee report (Hancock, 2019, pg. 8-9). Furthermore, their response significantly downplayed the committee’s findings and the problem’s severity, instead highlighting the progress made in spite of government inflicted cuts (ibid. pg. 6). There’s a justified fear that budget increases would project weakness for backtracking on major policies. Recent investment proposals in the 2024 budget still highlighted savings as the key driver, not patient care quality (Hunt and Huddleston, 2024, pg. 63), further indicating the Conservatives are unlikely to adopt this policy, especially during an election year when public perception is paramount. Labour have made numerous commitments to support community-based care, ICSs, and the social care workforce, by providing “fair pay and proper training” (Labour Party UK, 2023, pg. 4-6). This is promising for this policy’s success, though there’s no indication as to whether they’ll follow through if, or when, elected.
Unfortunately, evidence backed policies are often ignored for politically viable ones, and so advocating a large funding increase for a body experiencing significant negative press for perceived financial irresponsibility is an uphill battle. Both the public and policymakers’ perceptions and preconceptions must be utilised to market this policy effectively and overcome apprehension.
Summary
The UK’s SRHC system is in crisis. Constrained access to contraception and increased demand causes an unsatisfactory abortion rate, unacceptably varied teen pregnancy rate, and spikes in STI cases. More than a decade of harsh funding cuts to LAs and fragmented commissioning bodies have created huge barriers for providers and patients. Many proposed solutions are valid but won’t realistically work – mandatory speciality training is ideal but without funding, impossible, and a holistic commissioning system would’ve been ideal, but would cause too much disruption. Instead, there needs to be extensive investment in the public health grant, with a reserved minimum spend for SRH, and readily available funds for staff training. This proposal would provide adequate resources for services to continue to run, ease pressure on providers and reverse the downwards spiral of staff losses. It’s unlikely to be adopted under the current government due to their conservative fiscal policy and aversion to public infrastructure investment. With the upcoming election, concerns of stigmas could be overcome by tying it to a larger commitment to strengthen health and social care.
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