1.  MEDICAL FOUNDATION FOR AIDS & SEXUAL HEALTH

  1.1  The Medical Foundation for AIDS & Sexual Health, a charity supported by the British Medical Association, aims to promote excellence in the prevention and management of HIV and other sexually transmitted infections. We work by informing and advising health professionals on excellence in practice, and by briefing policy-makers. We welcome the opportunity to submit evidence to the Health Select Committee's enquiry into the effectiveness of the government's strategy on sexual health.

2.  SUMMARY

  2.1  The nation's sexual health is deteriorating. A strategy is badly needed and sexual health must become a higher public health priority.

  2.2  The focus of the National Strategy for Sexual Health and HIV is too narrow. Cross-government action is needed to tackle the broader determinants of sexual ill-health. Implementation must be coordinated with that of Getting Ahead of the Curve and other government strategies.

  2.3  Implementation of the Strategy must address current deficiencies in service provision. Investment must be radically scaled up in order to:

2.3.1  reverse the unacceptably long delays in access to Genito Urinary Medicine (GUM) services,

2.3.2  motivate and enable primary care to take on a significantly greater role in the provision of sexual health services,

2.3.3  maintain investment in HIV prevention while funding the growth in HIV treatment due to rising prevalence of infection.

  2.4  There are threats to effective commissioning in this specialised area because of the shift of responsibilities to Primary Care Trusts (PCTs). The government must put mechanisms in place to ensure local investment is at an adequate level and appropriately allocated.

  2.5  Standards are a tool for ensuring equal quality of service for all. By working together in managed networks, services are better able to meet standards. We provide some information about our work to develop new NHS HIV service standards and facilitate the development of HIV networks, supported by the Department of Health and others.

3.  NEED FOR THE STRATEGY

  3.1  The National Strategy for Sexual Health and HIV is badly needed. With no strategy in place until now in this area of health (except on teenage pregnancy), planning has been dominated by uncertainty, inconsistency and short-termism. If this continues, it is hard to see how the sexual health of the population will not continue to deteriorate.

4.  SCOPE OF THE STRATEGY

  4.1  Like many other organisations in the HIV and sexual health sector, we share the government's view that there is a relationship between sexual ill health, poverty and social exclusion, and that inequalities in health must be addressed. We believe that tackling such inequalities requires cross-governmental action to address the broader determinants of sexual ill health. This strategy concentrates almost exclusively on the NHS and medical solutions primarily. In our view this is too narrow. The strategy's effectiveness will be limited by its limited scope.

  4.2  We would also urge that the implementation of the National Strategy for Sexual Health and HIV be coordinated with implementation of other related government strategies, in particular Getting Ahead of the Curve, the strategy for communicable diseases.

  4.3  Our evidence focuses primarily on the implications of the Strategy for NHS services and their role in relation to HIV and other sexually transmitted infections. It includes information on the Medical Foundation for AIDS and Sexual Health's current work on HIV service standards in support of the Strategy.

5.  THE UK'S SEXUAL HEALTH

  5.1  The sexual health of the UK population is getting worse.

5.1.1  In 2001, the highest ever annual number of new HIV diagnoses was reported.

5.1.2  New diagnoses of other sexually transmitted infections (STIs) have been increasing year on year: annual totals for new cases of chlamydia and gonorrhoea have more than doubled since 1995 and those for syphilis have increased by half as much again.

5.1.3  Sexual health problems are a significant cause of ill-health and even death, for example unwanted conceptions, AIDS, pelvic inflammatory disease, ectopic pregnancy, infertility, cervical cancer, liver disease, and mental ill-health, including suicide.

  5.2  Prevention of these problems offers significant scope for public health improvement, as well as savings in NHS expenditure. But these cannot be achieved without adequate investment and sexual health must become a higher priority for government and commissioners.

6.  TACKLING SEXUAL ILL-HEALTH

  6.1  The National Strategy's objectives are good, and if achieved, would result in fewer new infections and lower levels of morbidity resulting from untreated infections. We agree that "better prevention" and "better services" are key to achieving the aim of "better sexual health".

  6.2  Better prevention should take place in a wide variety of settings, using a wide variety of techniques. These must include community-based interventions, both for the population as a whole and targeting populations at higher risk. But prevention must also take place within NHS services—through health promotion, which may influence behaviour change, and through treatment of those infected, which will reduce or eliminate onward transmission. NHS services also, of course, have an important role in reducing morbidity associated with existing infections through prompt and effective treatment and care.

7.  ACCESS TO DIAGNOSIS AND TREATMENT

  7.1  Prompt access to sexual health services, like access to other health services, is an important measure of service quality. But in the case of STIs, it must also be seen as a key public health measure. The longer individuals remain undiagnosed and untreated, the more likely they are to pass their STI on to their sexual partner(s). Rapid and open access to diagnosis and treatment must therefore remain a cornerstone of the UK's response and this becomes ever more important as prevalence of several STIs in the population increases.

  7.2  However, evidence about the state of access to UK services for diagnosis and treatment presents a very worrying picture.

8.  CAPACITY IN GENITO URINARY MEDICINE SERVICES

  8.1  Genito Urinary Medicine (GUM) clinic workload increased by 34% between 1995 and 2000, and at the end of that period the median wait for a first appointment was 5 days for men and 6 for women, already too long. By 2002, these waits have increased respectively to 12 and 14 days. Many clinics which used to offer a drop-in service now insist on booked appointments, while some others which maintain a drop-in service have to close the door on patients wishing to enter. In such circumstances, a significant number of potential service users will be put off attending altogether and those with STIs will remain infected. Not only will this lead to more new infections in the population, but those who wait longer before having their STI treated are also more likely to experience complications (eg untreated chlamydia leading to pelvic inflammatory disease which in turn can cause infertility). This situation must be addressed if the government's strategy is to be effective.

9.  CAPACITY IN PRIMARY CARE

  9.1  Increasing the availability of sexual health services in primary care is a way of increasing access for those who are unable, or prefer not, to use GUM clinics. However, the pressures on primary care are well-known and waiting times to see GPs for all health care needs are often too long. Sexual health competes with a long list of other health concerns in primary care, and many GPs would currently see the diagnosis and management of STIs as solely the role of specialist services. For primary care to become able and willing to take on a significantly greater role in the provision of sexual health services, it needs to be adequately resourced with GP and staff time, training, and facilities.

10.  HIV SERVICES

  10.1  With the welcome success of highly active antiretroviral therapy (HAART), the majority of people with HIV in the UK are able to live longer and healthier lives. But new infections continue to occur, so the total number of people living with HIV is growing, resulting in a growth in service demand and drug costs.

  10.2  Those who now become ill or die with AIDS are largely those whose infection is not diagnosed until very late. We therefore support the Strategy's aim of reducing the rate of undiagnosed HIV infection. This will necessitate increased capacity to provide testing in GUM above all, as well as in primary care and other settings, with adequate training for the professionals involved.

11.  RESOURCES AND IMPLEMENTATION

  11.1  The National Strategy's stated intentions in relation to GUM and primary care are to be supported, but there is little evidence to date that they could currently be implemented in a way that would have a significant impact on the problems outlined above. The allocated sum of £47.5 million over the first two years to implement the whole strategy is inadequate given the scale of the task in the short-term, and a commitment to continuing resources over the ten years of the strategy is also needed.

  11.2  The average annual cost of managing a patient with HIV in the UK is £15,000. It has been estimated that this will mean costs in excess of £345 million in the current year and with increasing prevalence (10% increase per annum is a conservative forecast) these costs will rise significantly each year. By 2007, estimates suggest that the cumulative lifetime treatment costs for those known to be infected with HIV would exceed £5bn. Against this backdrop, the Strategy's assessment of £0.5 million or more as the cost benefit of preventing a single case of HIV does not seem unrealistic. Preventing half the current annual new infections should provide a cost benefit of £1 billion.

  11.3  Services have an important role to play in prevention, through counselling, support, partner notification, and sexual health care for people with HIV. With the need to fund the growing cost of antiretroviral drugs, there has already been disinvestment from such activities and this is likely to continue. However, the above cost benefit estimates suggest such action is shortsighted and a false economy. Both treatment and prevention of HIV need adequate investment.

  11.4  Less work has been done on estimating the full costs of treating STIs and their complications, or the cost benefits of averting them. However, it has been calculated that, at current treatment costs, £7.5 million extra would be needed to meet the immediate shortfall represented by the 2-week waiting time for a GUM appointment. In practice this would be just a stop-gap and the problem will remain unless there is additional investment in expanding the workforce and supporting its professional development. The solution must be longer-term, with investment based on realistic forecasts of demand.

12.  STIMULATING DEMAND AND SUPPLY

  12.1  We support the Strategy's objective of increased promotion of, and access to, HIV testing. We also support the Strategy's objective of raising public awareness of sexual health risks and prevention, and would argue that this must include information on where to seek professional advice and help.

  12.2  It is self-evident that promoting uptake and increasing public awareness of sexual health services will increase demand. However, as demonstrated above, demand already outstrips supply. While improvements in the organisation of service provision can no doubt produce some efficiencies, the Strategy will fail if its implementation results in longer delays for an appointment. It must tackle both demand and supply.

13.  SERVICE LEVELS

  13.1  The three levels of service provision offer a flexible way of improving the consistency, quality and connectedness of sexual health services. We also welcome the move towards greater horizontal integration of different aspects of sexual health care, taking a patient-centred approach.

  13.2  Treatment for STIs is currently free in GUM services. If treatment is to be routinely provided at level 1 and 2 in primary care in an equitable way, this should also be free of charge.

14.  LABORATORY AND DIAGNOSTIC SERVICES

  14.1  Increased levels of testing for HIV and a range of other STIs, including through the chlamydia screening programme, will increase the demand on laboratory services. Less invasive but more expensive tests will save staff time and encourage uptake, but will also drive up costs.

  14.2  In HIV, the growing complexity of tests to support treatment decisions, such as those for viral resistance, requires the allocation of resources not only for laboratory work but also for the provision of expert advice to clinicians on the interpretation of results.

15.  COMMISSIONING HEALTH PROMOTION

  15.1  There is a compelling rationale for continued investment in health promotion. There is scope for both planned and opportunistic health promotion interventions by health care professionals, but such interventions need time. This should be allowed for when assessing the need for increased capacity in sexual health services and primary care.

  15.2  In addition, resources are needed to maintain specialist health promotion services, which can provide training and advice to health professionals, including primary care staff, and information materials for patients. These services also have an important role providing health promotion in the community, including work to target the most vulnerable population groups, the nature of which often requires them to work across PCT boundaries. The existence of such specialist sexual health promotion is threatened by the NHS changes outlined in Shifting the Balance of Power in the NHS and by the removal of the ring-fence on HIV prevention funding.

  15.3  Particularly threatened are HIV prevention activities with the marginalised groups (gay men, African communities, injecting drug users) who are most at risk. Such activities can be politically sensitive and may be tempting to abandon. For example, intensive outreach work with gay men is needed in the small urban area within a large city where gay bars and clubs attract customers from considerable distances. The PCT for the area where such a "gay village" is sited may be unwilling to foot the whole bill for such activities, when a large part of the target population is resident outside their locality. Meanwhile, the surrounding PCTs may not wish to fund prevention activities which occur outside their area, and may not even recognise that they have a local population of gay men with HIV prevention needs. Yet without such interventions, the strategy's challenging targets for reducing new HIV infections will not be met. We have already heard anecdotal reports of PCTs planning to withdraw investment from their share of HIV prevention activities previously purchased across a wider area.

  15.4  It will therefore be important for the government to put firm mechanisms in place to ensure adequate resources are invested by local commissioners in HIV prevention and maintaining specialist health promotion services. Such mechanisms might include guidance to PCTs on commissioning, and to Strategic Health Authorities on the functioning of public health networks and performance management.

16.  COMMISSIONING HIV TREATMENT AND CARE

  16.1  It has in the past been recognised that HIV treatment and care is "specialised". This role is now being taken on by PCTs, but there still seems to be uncertainty about how arrangements will work and whether, in all areas, HIV commissioning will be done across a wider area by lead PCTs. We are concerned about the ability of PCTs, faced with a plethora of competing priorities, to take on this "specialised" role. We would also like to know whether it will be possible for commissioning to take place through HIV service networks or if it will be purely through individual providers (eg NHS Trusts). See the final section of this document for more on service networks.

17.  SERVICE STANDARDS

  17.1  We strongly support the strategy's emphasis on the development of standards and believe these must be developed for all levels of service provision.

  17.2  It is important that services provided in other contexts, such as prisons or detention centres, offer equivalent standards of care. These need to take account of the particular circumstances, such as how to ensure continuity of treatment when prisoners are transferred or released. In relation to highly active antiretroviral therapy for HIV, the recognised risks of sub-optimal adherence to demanding treatment regimens make this more important than ever.

18.  NHS HIV SERVICE STANDARDS AND NETWORKS

  18.1  The Medical Foundation for AIDS & Sexual Health is managing a project to develop new standards for NHS HIV services. HIV is a relatively new and fast-changing area of health care and there has been much good practice and innovation to tackle it in the UK. However, services have tended to grow in an organic way and patterns of provision have varied around the country. Since the advent of HAART, patient numbers are steadily increasing and costs are growing. The changing profile of the epidemic presents new challenges around the country, eg more women and families affected, and dispersal of asylum seekers resulting in increasing HIV caseloads in areas which previously had very low prevalence. The UK response to HIV is now maturing and a more considered and strategic approach to service development is needed, taking account of broader changes in policy priorities within the NHS.

  18.2  There is support from service providers, service users and commissioners for the development of standards to guide the further development of services in a way that ensures people living with HIV have access to the same quality of care wherever they live. This is the focus of our new project, which is working closely with clinicians, people with HIV and voluntary sector providers to define the patient care pathway and the type of care that all service users should expect at each stage along it. We will be consulting on the draft standards in June and July 2002.

  18.3  At this time of upheaval in the NHS, moves in responsibility for commissioning, and the mainstreaming of HIV budgets, the standards should provide a tool for commissioning and performance management. There is widespread concern among professionals and service users in the HIV sector that NHS reforms have resulted in the loss of expertise in HIV commissioning and that PCTs, faced with a long list of other priorities currently ranked higher than HIV, risk damaging HIV services through under-investment or inadequately informed allocation of resources. The Department of Health has indicated that it will wish to endorse the new HIV service standards and we believe this will be vital to maximise their impact on commissioning and practice at local level.

  18.4  We also believe it is necessary, once the standards are available, to provide support to local commissioners and providers on how to implement the new standards, for example by offering guidance on good practice. Such guidance would be an important way for the government to increase the effectiveness of its Strategy.

  18.5  We support the Strategy's requirement for all HIV clinicians to work within a managed network. Our project aims to facilitate the further development of managed networks for HIV services. A mapping exercise we undertook in 2000-2001 demonstrated that there is a range of models of HIV service provision around the country, with centres linking up their work to a greater or lesser degree. Some HIV treatment centres are very small and do not have the capacity to provide the full range of specialist services to which people with HIV need access. Managing services through a network of centres, small and large, is a way of ensuring access to this range as well as consistency and continuity in the care of each patient. While much HIV service provision is based in hospitals, primary care also has a role to play (eg in diagnosis of HIV and in provision of basic health care for those infected) and should not be excluded from network development. The new standards, following the patient care pathway, reflect this. Managed networks provide a mechanism to enable services to meet all the standards, which many individual centres could not meet in full on their own.

  18.6  We are grateful for the support of the project's major funders, the Department of Health and London health authorities, and for additional contributions from the British HIV Association (BHIVA) and the Association of Providers of AIDS Care and Treatment (PACT). As the Select Committee reviews the effectiveness of the government's Strategy, it should note this project as one action point on which work is progressing well, with the support of a range of stakeholders. We are hopeful that the Department of Health will maintain its commitment in this area, and would encourage the Committee to add its voice in support.

19.  FURTHER INFORMATION

  19.1  We have not referenced this document but would be willing to provide further information or advice on source material if required. We would also be very happy to offer oral evidence to the Committee.

  19.2  An article summarising some of the findings of our project to map and facilitate the development of HIV service networks in 2000-1 is enclosed[1] (Ruth Lowbury and Oonagh O'Brien. Working Together for Quality in HIV Treatment and Care in AIDS & Hepatitis Digest. Vol 84, July 2001, p2. Royal Society of Medicine. Also available at http://www.rsm.ac.uk/pub/ahd84.pdf)

  19.3  For our response to the Department of Health's consultation on the National Strategy for Sexual Health and HIV, please see http://www.medfash.org.uk/publications/documents/national—strategy—response.html

May 2002