House of Commons - Health

Select Committee on Health Third Report

2 Follow up to Sexual Health Report

8. The Government published its National Strategy for Sexual Health and HIV in 2001.[4] The strategy, although it lacked the priority status of a National Service Framework, set out an ambitious framework for sexual health services. Our report into Sexual Health, published in June 2003, found that dramatic improvements in sexual health services were needed if the Strategy's aims were to be delivered. We were pleased to note from the evidence we received that many sexual health organisations and clinicians believe that our 2003 report into Sexual Health has raised the profile of sexual health and gone some way towards making it a higher priority.[5] However, in the 18 months since its publication, rates of STIs have continued to rise. According to data provided by the British Association for Sexual Health and HIV (BASHH), since the publication of the National Strategy for Sexual Health and HIV in 2001, overall STI diagnoses have risen by 11%.[6] The numbers of newly diagnosed HIV cases accelerate year on year. It is now estimated that a total of 53,000 people in the UK have HIV. Between 2001-2 and 2002-3 there was a 20% and 19% increase respectively of reported new diagnoses, although part of this upsurge may reflect increased efforts to encourage HIV testing.[7] STI diagnoses in England 1995-2003

Number of annual cases % increase

1995 2001 2003 1995-2003 2001-2003

All STI diagnoses 428,575 608,636 674,827 57% 11%

Syphilis 102 717 1,519 1,389% 112%

Chlamydia 29,241 68,256 85,550 193% 25%

Gonorrhoea 9,950 22,418 23,584 137% 5%

Genital warts 51,236 62,551 65,414 28% 5%

Genital herpes 15,021 17,076 17,173 14% 1%

Source: BASHH

9. Demand for sexual health services has also increased. There were over 2 million attendances during 2003 compared to just under 1 million in 1997,[8] and according to much of our evidence, service access and waiting times have continued to deteriorate. Professor George Kinghorn, a consultant physician in Sheffield, reported that in his clinic, over the period 2001-2003 there was a 73% increase in their annual total caseload and a 30% increase in new patient episodes.[9] We did not use the word "crisis" lightly when we described the state of sexual health services in 2003. We were therefore deeply concerned to hear Professor Kinghorn describe the current situation to us as "a continuing crisis".[10]

10. The evidence submitted to us in this inquiry raised several points concerning sexual health which need to be addressed. These are:

The current state of Genito-Urinary Medicine (GUM) services, including access and waiting times, facilities, and the potential impact of the proposed sexual health education campaign;
Funding for sexual health services;
Screening for chlamydia;
Sexual health in primary care, in particular the impact of the new GP contract;
Sexual health workforce and training requirements;
Contraception and abortion services;
Sex and relationships education in schools.

MedFASH study of sexual health services

11. Prompted by concerns about the challenges facing GUM services and their capacity to respond effectively, the Medical Foundation for AIDS and Sexual Health (MedFASH), which is an independent charity supported by the British Medical Association, was commissioned by the Department of Health to undertake a two-year national review of GUM services. According to MedFASH the review aims to:

undertake a multidisciplinary assessment of each GUM service in England, highlighting factors both facilitating and obstructing their ability to offer a prompt and high quality service,

offer recommendations for service improvement and modernisation arising from the assessment, to GUM clinics, Primary Care Trusts and Strategic Health Authorities,

provide findings and recommendations from the review to the Department of Health.[11]

12. The first phase of the review was a written questionnaire, sent to all GUM clinics in England in September 2004, about issues to be covered in more depth during review visits. A quantitative analysis of responses from the first 72% of clinics gives the most up-to-date snapshot available of the state of GUM services around the country. The questionnaire provides basic information on issues relating to current GUM service provision including facilities, length appointment per patient, capacity increases and PCT funding. As far as we are aware it is the only available source of such information, and the most accurate and up-to-date information about the state of sexual health services currently available.

13. MedFASH has now submitted its analysis to the Department of Health, which owns the data. MedFASH gave us details of the questionnaire, and told us that it would be happy for the data to be shared with us if the Department agreed. However, the Department has declined to supply it, arguing that it was still "work in progress".[12] When we pressed the Minister and Department of Health official on this point, we were told they had only recently received the data, and ministers and officials had not yet had time to consider it. The Minister told us that at the time of our evidence session, which was held on Thursday 10 February 2005, she had not yet received the information with advice from officials. Geoff Dessent, Deputy Division Head for Sexual Health at the Department, told us that he had only received the information "a few days" before our evidence session.[13] However, in the memorandum they sent in December 2004, MedFASH indicated that the data had already been submitted to the Department.[14]

14. We are concerned that it took at least seven weeks for the Deputy Head of the Sexual Health Policy Branch at the Department of Health to realise that the Department had been sent key data on sexual health which it had commissioned, and that the responsible Minister had not seen this data in advance of her appearance before the Committee. We are also surprised by the air of secrecy which surrounds this research, and can only surmise from this that it contains findings that would be unwelcome for the Government. If the Government places any value on the scrutiny work of Parliament, and takes seriously its commitment to co-operate with the work of Select Committees, it would seem counterproductive to withhold the most up-to-date information on sexual health services from the Health Committee when it is conducting an inquiry into precisely this subject.

Sexual health services

Access and waiting times

15. One of the key recommendations of our report was the introduction of a 48-hour maximum waiting time target for Genito-Urinary Medicine (GUM) clinics.[15] In its recent White Paper, Choosing Health, the Government accepted this as a target for 2008.[16] It will be included in PCTs' Local Delivery Plans from April this year, and will be monitored on a six-monthly basis.[17] However, although the 48 hour target has been broadly welcomed, our evidence suggests that over the next three years sexual health services will face a huge challenge in achieving it from the current position, as problems with waiting times seem to have become even further entrenched since the publication of our report.

16. In its evidence, the BMA cited waits of up to 12 days for urgent cases and eight weeks for general check ups[18], and in its first national audit of GUM waiting times, the Health Protection Agency (HPA) found that, nationally, only 38% people were seen at a GUM clinic within 48 hours of requesting an appointment, and 26% wait more than two weeks to get an appointment.[19]

17. The data also revealed significant regional variation in access to services, with the worst access outside London. In the North East region 44% of patients waited more than two weeks to be seen with only 27% seen within 48 hours; in the West Midlands 42% of patients waited more than two weeks to be seen with only 28% seen within 48 hours; in the Yorkshire and Humberside region and the Eastern region 31% and 33% of patients respectively had to wait over two weeks, with only 33% of patients able to access a service within 48 hrs.[20]

18. The national and regional picture was confirmed at a local level by evidence we received from a GUM consultant about his own service. Despite numerous innovations in service delivery at his Sheffield clinic, Professor George Kinghorn reported "a serious deterioration in GUM access times". Data from May 2004 showed that the numbers of patients who were able to access his clinic within 48 hours of first contact was only 20%. The average time to a routine appointment has now increased to around 3 weeks.[21] Professor Kinghorn confirmed in oral evidence that the situation was getting worse, both in terms of the prevalence of STIs, and in terms of access to clinics:

I think there is very definitely a worsening, an increase, in the incidence of sexually transmitted diseases, as evidenced by the cases of gonorrhoea and syphilis that we are seeing. These are new problems. Although some additional resources have gone into clinics, the amount of resource that went in was less than that recommended when we met with you previously. There is a widening gap between the patient demand and our clinic capacity and, sadly, I think that is going to get worse.[22]

19. Professor Kinghorn also explained the very real risk that, if patients are not seen promptly by GUM clinics, they will fail to come back, returning to the community with an untreated infection and possibly going on to infect others:

Mr Burns: Do you collect statistics or do you have any evidence that when someone goes to a clinic and they find that they have to wait possibly four, five, six, 10 or 12 days before actually seeing someone then they fail ever to turn up again?

Professor Kinghorn: Yes, there is a proportion of patients who will not come. This is particularly the case with the young. There is a window of opportunity and it is important that when individuals present they should be seen at that time, otherwise there is a risk that they will not turn up and they will continue to ignore symptoms.

Mr Burns: Do you think it is more likely that they will continue to ignore symptoms rather than that they will try and get help elsewhere, like going to their GP or whatever, or to another clinic, depending on where they live?

Professor Kinghorn: Some will try to go to other settings, but I think many will fail to turn up.[23]

20. BASHH provided us with a comparison of regional data for GUM waiting times for clinics set against the number of cases of STIs diagnosed in each region. This appeared to suggest that increasing diagnoses of chlamydia, gonorrhoea and syphilis were associated with increased waiting times. BASHH pointed out that "the argument that increased delay to diagnosis and treatment provides greater opportunity for onward transmission of infection is compelling." [24]

Facilities

21. Another major problem highlighted by our previous report was the dire state of GUM facilities, which were frequently located in portacabins.[25] Evidence from Professor Kinghorn suggested that this has continued to be a problem, and that it is likely to have an impact on plans to increase the capacity of services:

Any further expansion of workload is severely impaired by serious space constraints. Our dedicated clinic premises were designed 25 years ago for less than half the current workload. In order to increase patient throughput, we have a very urgent need for additional consulting rooms and appropriate accommodation for personnel. The department was selected as the Strategic Health Authority choice for a share of the designated £15 million capital funding for GUM infrastructure. This funding was inadequate and was eventually allocated only to those services currently in temporary accommodation e.g. portacabins. Whilst this is understandable, this leaves significant accommodation/capacity issues that are pressing in Sheffield and elsewhere, which require a substantial increase in targeted capital allocations.[26]

Sexual health education campaign

22. In its White Paper, the Government announced a new £50 million sexual health education campaign.[27] However, the Medical Foundation for AIDS and Sexual Health (MedFASH) argued that "this is bound to increase the demand for services" and that "this increased demand will put a further strain on capacity".[28] Several memoranda recommended that this should be delayed until more capacity exists within GUM services, so that public expectations can be met.[29] Professor Kinghorn reinforced this point in oral evidence:

We are in a bit of a dilemma. I wish to encourage people to take responsibility. I wish to encourage people to take that personal responsibility for their health and for the health of their partners, but, unless capacity increases go hand-in-hand with the education campaign, then there is a risk that services which are under severe pressure would be in a state of collapse. The concern we have at this present time is that new resources for capacity may not become available until 2006-07, which will be after the education campaign has been proposed. That, in our view, would lead to a great dissatisfaction amongst the public because we could not cater for the obvious increase in demand.[30]

23. We welcome the Government's adoption of our recommendation of a 48-hour access target for sexual health services. However, the Government should take note of the warnings we have been given by clinicians that this target may not be achieved within the timeframe specified by Government without additional spending, and that inadequate facilities may present a barrier to service expansion.

24. We also welcome the Government's adoption of our recommendation for a dedicated health education campaign aimed at improving sexual health. However, the Government should not begin the campaign until it is certain that services have the extra capacity they need to meet the extra demand the campaign will generate.

Funding

25. Clearly, if access times are to be improved in line with the Government's goals, capacity in GUM services must be built up to cope with present and future demand, which requires funding. According to the Department, a total of £300 million has been earmarked for sexual health services over the next three years, which breaks down as follows:

£130 million capital and revenue funding over three years for GUM services

£50 million to fund a health education campaign

£40 million to fund an audit of contraceptive services and to rectify problems

£80 million to fund the chlamydia screening programme.[31]

26. This extra investment was universally welcomed by our witnesses, but several key questions remain. Firstly, will the extra investment be enough? Secondly, will the funding be delivered quickly enough to enable clinics to cope with the expected increase in demand for services? Thirdly, will the funding be guaranteed to reach clinics, or is the possibility that it may be used by PCTs for other priorities? And, finally, does the funding announced represent new money, in addition to what GUM clinics have already been provided with?

27. £130 million of capital and revenue funding has been promised to GUM clinics by Government over the next three years. However, it is not clear exactly how the £130m funding will be divided between capital and revenue expenditure, and nor is it likely to be enough. Estimates submitted to our previous inquiry into sexual health by Professor Kinghorn in 2002 suggested that an additional revenue commitment of £22m-£30m per annum would be required to fully meet demand for sexual health services, and evidence provided by the Association of Genito-urinary Medicine suggested that around £150m of capital funding would be needed to modernize GUM facilities.[32] The funding will also need to reach clinics rapidly if its impact is to be felt in time to meet the Government's access targets for 2007, and it is not clear whether or not this will happen.[33]

28. We welcome the extra investment for GUM services of £130 million over three years, but evidence submitted to our previous inquiry into sexual health suggested that the true funding needs of GUM services may be far greater than this. Estimates provided by the Association of Genito-urinary Medicine suggested that around £150m of capital funding alone would be needed to modernize GUM facilities, and on top of this we were given evidence of the need for up to £30 million per year additional revenue funding for GUM services, giving a total of some £240 million. The Government should keep the funding of GUM services under close review and be prepared to increase allocations if this should prove necessary.

29. The welcome for the extra funding has also been tempered by reports that the previous money earmarked for sexual health services has not reached its intended destinations. According to BASHH:

The 2004 DH figure for investment and modernising in GUM services is £26 million; In January 2003, 90% of £5 million allocated direct to GUM clinics was received. £10 million was allocated as recurrent funding in 2003/04 of which £8 million was distributed to PCTs by July 2003. Only 64% of clinics received their full allocation. Of a further £5 million of non-recurrent money given for GUM services in January 2004, approximately 50% of the money reached its intended destination.[34]

30. BASHH went on to report other examples of Trusts agreeing to carry over the money to 2004/5, but the money then being used for more "pressing priorities":

A GUM consultant negotiated that £58K was carried over from 2003/4 to 2004/5. Job descriptions were ready, an advertisement placed when she was informed by her immediate manager that this money was no longer available. It was required for an overspend elsewhere. She raised this with the PCT Sexual Health Commissioner, Strategic Health Authority Public Health Lead having failed to influence the Chief Executive. She has been told to keep quiet and stop making a fuss.[35]

31. Professor Kinghorn described a similar situation:

GUM clinics were notified by the Department of Health of non-recurrent allocations of additional funding beginning in 2003 to promote additional capacity. Only half of the initial £140,000 allocation designated for GUM was received. The remainder was retained by the PCT for other purposes not related to sexual health. This failure to receive the total funding, which was justified by the PCT on the basis that GUM services were not a national or local priority, significantly impaired confidence and our ability to expand service capacity in a timely fashion.[36]

32. Although this dispute was eventually resolved, it illustrates the problems sexual health faces in not being a national priority. Professor Kinghorn also pointed out that as his clinic is now part of a Foundation Trust, it attracts full tariff funding for overperformance against the baselines agreed in the service level agreement. However, non-Foundation Trust GUM clinics only receive marginal costs for additional workload that do not cover the step costs of delivering more patient service.[37]

33. According to the Minister, changes to monitoring arrangements will mean that NHS performance in the area of sexual health will in future be subject to far closer scrutiny than has previously been the case. The funding and provision of sexual health services is to be monitored by Strategic Health Authorities through PCTs' local delivery plans, and clinics' progress against the 48 hour access target will be monitored on a six-monthly basis. However, if the extra funding for GUM services is still provided to PCTs rather than directly to GUM clinics this may not guarantee that funding reaches its destination.

34. We welcome proposals to improve performance monitoring around sexual health. However, we remain very concerned by reports that previous allocations for GUM services, when filtered through PCTs, often did not reach the services for which they were intended, but were siphoned off to fund services identified by PCTs as being of a higher priority. To ensure that this does not happen again, we recommend that, at least for the next three years, the Department supplement its existing performance management of sexual health services by commissioning a specific financial audit to check that funding has reached its intended destination. The audit could be carried out by the Audit Commission or the Healthcare Commission. The results of the audit should be published to identify any funding gaps that may occur.

35. The Department, in its response to this Report, should also supply us with a detailed breakdown of the £300 million funding for sexual health services, specifying whether the funding is entirely new, or is part of the total funding for PCTs already announced, as implied by the Minister.

Screening for chlamydia

36. Chlamydia is now the most common sexually transmitted infection in the UK, with 89,431 new diagnoses last year.[38] It is a disease which predominantly affects young people. 68% of diagnoses last year were in people aged under 25.[39] Data indicates that approximately 10% of young men and women between 16 and 25 in this country are infected.[40] Chlamydia can be easily treated once diagnosed, but because it is asymptomatic in 70% of women and 50% of men, it often goes undiagnosed. This is deeply concerning, as, left untreated, it can have serious long term consequences including pelvic inflammatory disease and infertility.

37. During our previous inquiry into Sexual Health, we heard that a Government-funded pilot screening project involving 17,000 young women had proved effective, but was facing hold ups in being extended throughout the country. We recommended that the Government extended this screening programme nationwide without delay, and also that the Government explored ways of screening young men.[41] In addition to this, during our previous inquiry we learnt that a sub-optimal test (the enzyme immunoassay or EIA test) which missed 30% of chlamydia infections was still being used by the majority of service providers, despite the availability of a far superior test, the Nucleic Acid Amplification (NAA) test. We therefore recommended that the most effective test be introduced immediately.[42]

National chlamydia screening programme

38. Rather than a proactive call-and-recall system, where people receive invitations to attend local health services specifically for screening tests at regular intervals, as happens in the national cervical and breast cancer screening programmes, the national chlamydia screening programme is an opportunistic screening programme, where patients are offered screening tests for chlamydia, but only if they happen to need to attend health services for another reason. Each individual area determines the different settings where opportunistic chlamydia screening will be made available. Guidance specifies that chlamydia screening should be available within contraception clinics, young peoples' services, gynaecology departments (including early pregnancy assessment units), antenatal services, colposcopy services, termination of pregnancy services and General Practice. Screening may also be offered in a variety of other settings, including GUM clinics, universities, colleges and schools, and military health services.[43] Ten opportunistic screening programmes were implemented in 2002, with a further 16 programmes announced in January 2004. The scheme currently covers over 25% of PCTs in England.[44] The White Paper announced the goal of nationwide coverage for chlamydia screening by 2007.[45]

39. Despite the welcome extension of the screening programme, we have received evidence to suggest that problems still persist within this important area of sexual health. According to several witnesses a key problem with the Government's national screening programme is the limited nature of the population it covers. Firstly, despite the latest research evidence suggesting that it remains beneficial to screen people for chlamydia up to the age of 30, the Government's screening programme does not cover anyone over the age of 25.[46] Thus it excludes a large group of people in their late twenties still at significant risk from chlamydia infection and its consequences.

40. Secondly, and perhaps even more importantly, it is obvious that even if all women infected with chlamydia are identified through screening, reinfection will continue at the same rates if men who have chlamydia are not also identified and treated. Professor Kinghorn therefore argued that men must be screened as well:

The prevalence in young men under the age of 25 is also about one in ten, or more. It is important that we should be encouraging young men, as well as young women, to be screened.[47]

41. When we put this to the Minister, she agreed on the importance of testing men as well as women, but implied that current efforts to target young men were sufficient:

In the interviews I have done myself in the last few days I have been emphasizing young men as much as young women. Obviously both sexes are infected, otherwise the problem would not be there at all. We need to make sure that both sexes come forward. In fact, we have specific screening programmes running around prisons and also MoD facilities, so there is some specifically targeted largely at the male population, but we want to see both sexes come forward for screening.[48]

42. However, as the White Paper makes clear, women are the major focus of the screening programme:

The 1.2 million women who attend contraception services each year - the vast majority under 25 years old - will be the main focus for offering screening as well as wider health advice.[49]

43. Both men and women should be screened for chlamydia. We are concerned that current efforts to screen men are insufficient. Furthermore, by introducing the cut-off for the screening programme at 25 year-olds the Government also risks missing a significant proportion of young people who remain vulnerable to chlamydia infection and its consequences. We therefore recommend that the national chlamydia screening programme be extended to men as well as women, and that the target age range be extended from 16-25 year olds to 16-29 year olds, at least initially. If it is subsequently shown that chlamydia screening is beneficial across a wider age range than this, the Government should extend the programme accordingly.

44. In addition, we note that there are limits to what can be achieved by an opportunistic screening programme, which relies on people seeking out healthcare services for another reason, such as contraception, rather than proactively inviting them to attend for a test. This may pose particular problems in screening young men, as research suggests that young men generally attend health services less frequently than women. We therefore recommend that the Government monitors the rates of chlamydia infection closely to assess the effect of the national screening programme, and that, if rates of chlamydia continue to increase, it considers supplementing the opportunistic screening programme with a proactive call-and-recall system targeting specific high-risk groups.

Availability of appropriate testing technology

45. In its response to our 2003 report into Sexual Health, the Government stated that it was "taking action to ensure that nucleic acid amplification (NAA) testing is available in every region" and that it would provide an £8 million "pump priming fund" to enable NHS laboratories to make the changeover.[50] However, despite the Government's commitment to using the most effective testing systems to detect chlamydia, and the £8 million they have earmarked for this, BASHH stated in evidence to us that almost half of all GUM clinics still do not have NAA chlamydia testing available for all men and women attending as patients. It estimated that in 2004 45% of laboratories were still using EIA test methodology and 45% of all chlamydia tests were undertaken using EIA, which misses 30% of infections.[51] While the extra funding for the new test announced by the Government in response to our report was welcomed by BASHH, it also pointed out that it will not come into effect until the financial year 2005-06.[52]

46. BASHH described the current situation with regard to different types of chlamydia screening as a 'postcode lottery'.[53] NAA testing is being introduced as a priority in those areas which are taking part in the chlamydia screening programme, but this means only 25% of PCT areas so far. There is also inequity within areas that have the NAA testing available. BASHH told us that currently, in areas which have financial support for the chlamydia screening programme, NAA testing would be available for under-25s presenting in community and other screening settings, but that the GUM Department would often still have to use EIAs.[54] This means that, if a young person is concerned that they might have chlamydia and decides to seek a test, whether or not they are given an effective test will depend not only on the area in which they live, but also on what type of health service they decide to visit.

47. The Government has given a commitment that NAA testing will be available in all areas by 2007, but according to BASHH, the funding allocated to change test methodology will not impact until the financial year 2005/6. This could potentially lead to difficulties in meeting the 2007 target. Professor Kinghorn pointed out that ensuring that NAA testing was technically "available" in all areas may not necessarily mean that all patients have access to NAA testing. He also expressed doubts about the 2007 target:

I hope that it is going to be available by 2007, but I think there may well be difficulties in achieving that date. [55]

48. It is unacceptable that a test is still being used for chlamydia which may miss as many as 30% of infections, when a far more accurate test is available. We are pleased that the Government is to make NAA testing available in all areas, but disappointed that this will not happen until 2007. Some clinicians even doubt that this target can be achieved. The Government will need to monitor this target carefully over the next two years to ensure that NAA testing is, indeed, universally available in all clinical settings by 2007.

Sexual health in primary care and the new GP contract

49. While specialist sexual health services are usually provided in open-access genito-urinary medicine (GUM) clinics attached to hospitals and specialist contraceptive services are often provided in specialist community family planning clinics, the National Strategy for Sexual Health and HIV acknowledged the potential for primary care to play a crucial role in the provision of all types of sexual health services, including screening and contraception services.[56] In our 2003 report, we recommended that the new GP contract recognize this vital role for GPs.[57] However both the Royal College of General Practitioners and Dr William Ford-Young, a GP with a special interest in sexual health, told us that the new GP contract had provided no incentives at all for GPs to address sexual health or improve the quality of services they provided in this area.

50. Services provided by GPs under the GP contract are currently divided into three categories:

Essential services, which all GPs must provide - this general category covers the treatment of individuals who are unwell, or have a chronic or terminal condition;
Additional services, which GPs can opt out of, but which PCTs must allow GPs the opportunity to provide - contraceptive services and cervical screening fall within this category
Enhanced services, which GPs can provide in agreement with PCTs - fitting of intra-uterine contraceptive devices, and specialized sexual health services fall within this category.

51. There appears to be some confusion over what types of sexual health services should be provided under "Essential Services". The Family Planning Association (FPA) provided anecdotal evidence that some general practices are declining to offer any sexual health services at all in the belief that they are not covered in essential services. [58]

52. According to Dr Ford-Young, the "holistic nature of sexual health and levels of service provision in National Strategy for Sexual Health" are entirely ignored by the GP contract - instead, different elements of service in the Strategy are segregated and placed in various separate "add-on" elements of the contract or are not included at all.[59] For example, condom provision is not included within the definition of contraceptive services, which is an additional service, but only within more specialized enhanced sexual health services. Therefore if a GP provides a woman with contraceptive services under the "additional services" heading, they may prescribe her with any form of contraception, but not supply her with free condoms to prevent STIs.

53. A comprehensive framework has been published describing the sexual health services expected under "National Enhanced Service for More Specialised Sexual Health", but Dr Ford-Young argued that this was "beyond most practices' skills and capabilities at present" and stated that very few PCTs were currently commissioning such services.[60]

54. Dr Ford-Young also pointed out that the National Chlamydia Screening Programme was not at present supported by the GP contract, despite this being, in his view, the most important element of the National Strategy for Sexual Health and HIV, with the potential to be a main driver to improve the sexual health of the nation.[61]

55. Under the new GP contract, payments to GPs are also affected by a system of quality points, where quality markers have been put in place to reward the achievement of high standards in certain priority clinical conditions. There are no quality points at all available for sexual health within "Essential Services". Within "Additional Services" there is currently one quality point available for having a written policy for responding to requests for emergency contraception and one quality point for having a policy for pre-conceptual advice, but as Dr Ford-Young pointed out, this is hardly an incentive to encourage practitioners to increase their own or their patient's STI awareness, especially out of a total of 1,050 quality and outcome points available under the contract.[62]

56. Dr Ford-Young told us he felt that regarding sexual health, there had been "a great missed opportunity in our new GMS contract". As he went on to explain:

We see a lot of patients through our doors. We provide up to 80 per cent of contraception services in England and, in a way, we are the sleeping giant of sexual health services. Your Committee and we ourselves were optimistic that our new contract would help improve the provision of quality of care for sexual health but, unfortunately, it does not. It appears to have ignored the National Strategy for Sexual Health and HIV.[63]

57. The Minister did not share the view that the GP contract was a missed opportunity to involve GPs in sexual health. She stated that GPs could have a role in sexual health if they wished, but she did not see their contribution as any more important than other potential providers within a "mixed economy". She emphasised that community pharmacists could be equally important:

There are a lot of different providers who are clearly very keen to provide, and when you say GPs can obviously do this, obviously GPs can, and we hope that they will continue to do so, but we are looking for a mixed economy so that there is a variety of patterns of provision that both meet the individual needs of that particular community, as it were, rural, urban and all the rest of it, but also meet the needs of different sections of the population. For example, community pharmacies may well be one route in a community setting. The GP is one community setting alternative for the provision, but it is by no means now the only alternative.[64]

58. We are disappointed that the Minister does not appear to share the view of many leading authorities in the area of sexual health that primary care services are a huge untapped resource for delivering sexual health services, and crucial to improving the nation's sexual health. Indeed, the Government's own Strategy on Sexual Health and HIV set out a key role for GPs. While we do not want to downplay the potential role of community pharmacies, it is clear they are unable to provide the same level of service as a GP or a specialist sexual health clinic. Moreover, most community pharmacies are not yet in a position to be able to offer sexual health services. By contrast, most of the population is registered with a GP, and GPs currently provide 80% of contraceptive services. Consequently, GPs are uniquely well placed to offer opportunistic screening or health promotion advice in the area of sexual health.

59. We asked the Minister whether sexual health had featured in negotiations over the GP contract, and whether there were plans to review the contract. She informed us that there were no plans to review the GP contract[65], but Geoff Dessent, the Department of Health official, told us that in fact there would be a review of the contract, and that the Department would be putting forward the case for including more incentives to promote sexual health services:

Obviously, in terms of the development of the GMS contract, yes, of course we were involved in discussions about that, and made the case for where it might be introduced. I probably should say that there will be at some point a formal review of the GMS contract, and we will be making those same arguments again to see whether there are particular avenues that might be explored that would start to address some of the points that you are raising.[66]

60. The initial negotiations over the GP contract were a wasted opportunity to mobilise GPs to tackle sexual health. We are therefore pleased to hear from the Department of Health official that a formal review of the GMS contract will take place. We recommend that the Government and the BMA review the contract as soon as possible. We further strongly recommend that the Government negotiates for the inclusion of sexual health services within the "Essential Services" or "Additional Services" headings of the contract, with the introduction of quality points to encourage GPs to provide these services.

61. The Minister told us that the purchasing of sexual health services was now entirely in the hands of PCTs: "the PCTs …have the money and the money follows services, as it were; it follows the patient."[67] However, we were told by other witnesses that PCTs were part of the problem. Dr Ford-Young argued that it was possible for GP practices to provide more specialized sexual health services, perhaps for a group of practices. However, PCTs did not see such services as a priority and there was "a reluctance" amongst PCTs to commission them.[68] This view was supported by the RCGP, which argued that one way to overcome the shortcomings of the contract in the area of sexual health would be for PCTs to commission sexual health services from GPs with Special Interest, with appropriate support staff. However, according to the RCGP, "PCTs are reluctant to commission enhanced work even that which is already outlined in the contract let alone work outside of it."[69] Dr Ford-Young went on to suggest that PCTs may lack sufficient expertise to commission sexual health services effectively:

When we lost health authorities and moved to PCTs and we were shifting the balance of power, we actually lost a lot of expertise and competence around commissioning sexual health services, especially some of the more specialised sexual health services like HIV treatment and care. I feel a PCT is too small a body to be commissioning at that level because the more specialist services lie across several PCTs.[70]

62. Dr Ford-Young also recognised that GPs were well placed to undertake chlamydia screening, but explained that as screening is not seen as an essential service, it would need to be properly supported and resourced. He argued that anecdotally, in his area, about 50 per cent of practices wanted to be involved in the chlamydia screening but felt the GP contract was getting in the way of being able to find the resources to provide that service.[71] Mr Dessent suggested that when the time comes to renegotiate the GP contract chlamydia screening may be included, as "certainly chlamydia is one of the issues that we particularly recognise as being relevant to this [the GP contract] ."[72]

63. We are pleased that the Department recognises the advantages of GPs undertaking chlamydia screening. We recommend that the Department makes provision for such screening when it reviews the GP contract.

Sexual Health workforce and training

64. During our previous inquiry, we were informed that there were 90% fewer GUM consultants than the Royal College of Physicians recommended.[73] BASHH stated in their latest evidence to us that consultant numbers have risen by only 4% between 2002-2003, and that nearly 16% of consultants are still single-handed (i.e. working in a clinic where they are the only consultant) as opposed to 19% in 2002.[74] Professor Kinghorn argued that it would be necessary to provide sufficient consultants to deal with an expected increase of GUM patient throughput of between 30-50% before 2008.[75]

65. Professor Kinghorn also argued that it would be essential to provide practical training for dozens of primary care practitioners to provide a similar or greater increase in capacity at community settings. To achieve this, he recommended the establishment of a dedicated sexual health-training budget.[76]

66. Dr Ford-Young told us that there was at present no nationally provided or recognised education and training programme that exists to support and train GPs and Practice Nurses to provide sexual health services in primary care.[77] He suggested that a useful model might be the training programme for primary care management of substance abuse, which had government funding and backing from the RCGP.[78] He argued that such a training programme would have the added benefit of helping to make it normal for GPs and their patients to talk about sex and sexual health.[79]

67. In our previous inquiry, serious concerns were raised about shortages of consultants who specialise in sexual health. Our evidence suggests that the situation is little improved since then and that it may be necessary to provide sufficient consultants to deal with an expected increase in GUM patients of between 30-50% before 2008. We recommend that the Government takes account of this in its workforce planning.

68. It is essential that GPs and practice nurses are properly trained and supported to provide sexual health services. We therefore recommend that the Government develops a sexual health training programme for primary care clinicians, possibly modelled on the successful training programme for the primary care management of substance abuse. This must be funded by a dedicated training budget.

Contraception and abortion services

69. In our 2003 report, we highlighted contraception and abortion services as a largely neglected area of sexual health services with a particular need for higher priority.[80] The Family Planning Association (FPA) submitted detailed evidence on contraception and abortion services to this inquiry, arguing that better sexual health choices need to be made available to patients through the integration and joining-up of services, so that, for example, people could access STI screening at a family planning clinic and contraceptive services at a GUM clinic. While they did not believe that it would be necessary to have a combined service in every setting, they argued that GUM and family planning services must be linked together and seen as part of one sexual health service. By the same token, they thought that it should be an urgent priority for PCTs to recognise the links between contraceptive and abortion services and to integrate their approach accordingly.[81]

70. According to the FPA, the new system of Payment by Results is a potential barrier to such service integration if services are paid for separate family planning or GUM consultations.[82] They also argued that services should not be organised on the basis of payment by visit rather than by treatment, as this could have an adverse impact on the choice of contraceptive methods offered to patients. For example it could militate against provision of longer-acting contraceptives which last for a number of years (e.g. IUDs, implants, etc.), and could instead incentivise repeat prescriptions of oral contraceptives at more frequent intervals.[83]

71. We recommend that the Government takes steps to promote and facilitate better joint working between GUM and family planning services, in order to move towards the integrated model of sexual health services set out in its National Strategy for Sexual Health and HIV. This should include addressing any potential difficulties which may arise through new funding and purchasing arrangements.

72. In line with our recommendations, the Public Health White Paper announced that an audit of contraceptive service provision would be carried out in 2005, followed by central investment to meet gaps in local services.[84] The FPA welcomed this, and argued that it would be vital for general practice contraceptive provision to be included in the audit as well as family planning clinics.[85] We were pleased to receive reassurances from the Minister that this would be the case.[86]

73. The FPA also emphasised the need to improve the quality of contraceptive services, and argued that wherever users access contraceptive services, they must have access to all contraceptive methods.[87] We were told that, admittedly according to anecdotal evidence, not all services currently offer all methods, in particular in general practice where the majority of contraceptive advice is given.[88] The FPA also argued that the GP contract's lack of quality points for the provision of contraceptive advice "seriously undermines this aspect of the contract, and does not incentivise general practice to provide a comprehensive contraceptive service."[89]

74. We are pleased that the Government has accepted our recommendation to conduct an audit of contraceptive services, with attached funding to rectify any problems, and that this audit will include GP contraceptive provision. We look forward to receiving the results in due course. We recommend that the Department, in its review of the GP contract, consider introducing incentives for GPs to deliver higher quality contraceptive services.

75. According to the Government's National Strategy for Sexual Health and HIV, abortion is one of the main elements of a "modern, comprehensive sexual health system".[90] Prompt access is very important in abortion services, as the procedure becomes more complicated and distressing as a pregnancy proceeds. The National Strategy for Sexual Health and HIV introduced a target that from 2005, commissioners should ensure that women have access to abortion within three weeks of the first appointment with the GP or other referring doctor.[91] PCTs are also currently monitored on the percentage of NHS-funded abortions that are performed under 10 weeks in their area. It its evidence to us, the FPA recommended that there should be a target waiting time of 72 hours for abortion, with one week as a minimum standard.[92]

76. Our 2003 report recommended that the current guideline of three weeks maximum wait for an abortion was too long, and recommended that, to improve this, the Government considered an open access model of service provision, provided in a wider range of settings.[93] The FPA expressed disappointment that despite this the recent Public Health White Paper did not include any initiatives on abortion services.[94] When we asked the Minister why this was, she simply replied that:

Our White Paper does not mention an awful lot of things actually. We decided to leave many things out of the White Paper. It would have been a huge document had we included everything that technically belongs to public health.[95]

77. We are surprised that although the White Paper devotes an entire section to sexual health, it does not discuss abortion services. They are an important aspect of sexual health services, as the Government's 2001 Strategy acknowledged. It is crucial that the Government retains the National Strategy for Sexual Health and HIV's target that from 2005 commissioners should ensure that women have access to abortion within three weeks of the first appointment with the GP or other referring doctor. The Healthcare Commission should also retain its PCT performance indicator of the percentage of NHS-funded abortions performed under 10 weeks.

Sex and Relationships Education

78. So far, this report has largely focused on various issues to do with treatment of, and screening for, sexual health problems. However, improving people's sexual health through prevention rather than cure remains the ultimate challenge for all those working in the area of sexual health, and this is never more the case than with young people. In oral evidence to us, Dr Ford-Young argued that education is a vital part of young people's sexual health:

As a general practitioner, I have an advantage in that when I see a patient I can provide some education, but that is all too often too late because they may be presenting me with a problem and we have missed the boat. That has to take place in education and not be left to health.[96]

79. The basic biology of sex and relationship education is part of the statutory science element of the National Curriculum. By Key Stage 3 (ages 11 to 14), a child should have learnt about reproduction, and the changes that they will go through at puberty. By Key Stage 4 (ages14 to16), a young teenager should have learnt in more detail about the process of conception, and how hormonal methods of contraception such as the pill work to prevent it. The theory of how some sexually transmitted infections are spread should also be referred to as young people learn, as part of the National Curriculum in science, about viruses and how they are transmitted, but this will not necessarily cover all STIs.

80. However, these isolated biological facts are the only aspects of sex and relationships education that have a compulsory statutory basis. The biological facts are intended to be supplemented by, and interwoven with, a broader sex and relationships curriculum, which includes the social and emotional aspects of sexual relationships, through a dedicated framework for "Sex and Relationships Education" (SRE), which forms part of the Personal Social and Health Education (PSHE) curriculum. This broader SRE and PSHE curriculum is not statutory.

81. Guidance on SRE was issued by the DfES in 2000.[97] This guidance specifies that at primary school, children should be taught about puberty and menstruation, and at secondary school about contraception, abortion, and STIs including HIV and AIDS, all against a backdrop of education about relationships. However, as this guidance is not statutory, Boards of Governors within individual schools have considerable discretion as to how it is implemented in individual schools. Pupils do not sit examinations or assessments in SRE or PSHE. SRE may be covered within a school's OFSTED inspection, but in practice this may mean no more than checking the school's policy or discussing it with a teacher.

82. Sex and Relationships Education (SRE) formed a key aspect of our previous report into sexual health. Amongst other things we recommended:

Renewed emphasis on the 'relationships' aspect of sex and relationships education
Location of SRE within the National Curriculum to ensure it received adequate priority
Use of specialist teachers to teach SRE
Young people's health services to be integrated within schools.[98]

83. Anne Weyman of the FPA raised this issue with us, and reported that in her view there had not been very much progress since our previous report:

Although the Department of Education says that it is committed and then there is guidance for schools, it is quite clearly not happening. I think we have to go on making the demands for sex and relationships education to become a broad programme, not the small amount of sex education that is currently compulsory but that we have this within the National Curriculum from an early age.[99]

84. A recent report into PSHE by OFSTED generally endorsed this view, identifying many shortcomings in this area:

Perhaps the most significant weakness in PSHE relates to assessment. Currently, there is little assessment of pupils' subject knowledge or of their progress
Some schools do not provide the subject in any form.
Some schools have included other subjects such as citizenship within their PSHE programmes. Of these schools, too many have failed to ensure that the curriculum and teaching time for PSHE has not been adversely affected by the demands of provision of National Curriculum citizenship.
The quality of teaching by specialist teachers remains considerably better than that of non-specialist form tutors. Where tutors are teaching PSHE, they are given insufficient training to help them improve their subject knowledge and the teaching skills needed in the subject.
In many of the schools where PSHE is taught by form tutors the curriculum can be placed under…pressure. Here, the problem is caused by a lack of clarity between their roles and responsibilities as a tutor and that of the PSHE teacher. This lack of clarity between the two roles leads to a reduction in the time for PSHE as tutors give too much time to other activities such as monitoring pupils' progress and target setting.[100]

85. We took oral evidence from Julie Bramman, a senior official at the Department for Education and Skills. Ms Bramman agreed about the importance of ensuring that young people receive education about sex and relationships from specialist teachers who are both competent and confident in teaching children about such sensitive subjects:

I think the key points that come out of the Ofsted report are around teacher confidence and teacher competence in actually teaching sex and relationship education within PSHE….We think that that is really what we need to be doing, making it part of a specialist process, which it has not traditionally been, with geography and history, as it is quite clearly a specialist subject, rather than leaving it to form tutors which seems to be the majority of practice at the moment [101]

86. Ms Bramman also told us that 2,000 teachers were currently training to become accredited in PSHE tuition, either as their main specialism, or as a secondary specialism.[102] We welcome the acknowledgement by the Department for Education and Skills that Personal Social and Health Education (PSHE) and Sex and Relationships Education (SRE) lessons are far better taught by specialist teachers than by form tutors, and are pleased that increasing numbers of teachers are completing specialist training to becoming accredited PSHE teachers. However, we remain deeply concerned that, by DfES's own admission, in the majority of schools PSHE and SRE lessons are taught by form tutors rather than by specialist teachers. We therefore recommend that the DfES issue specific guidance to schools stipulating that by 2007 all PSHE and SRE lessons must be taught by specialist accredited PSHE teachers rather than by unqualified form tutors. These teachers should build up and maintain links with clinicians working in sexual health, including community nurses and GPs, who can often contribute very usefully to SRE but who should not be used as a substitute for a qualified SRE teacher.

87. Other concerns raised in the OFSTED report related to the fact that PSHE is not assessed, and that it is often afforded insufficient time and priority within the school curriculum. The most extreme example of this was of schools reported by OFSTED to be failing to provide any PSHE at all. Ms Bramman told us that in the case of those schools,

We will clearly have to have very serious conversations with the school about ensuring it has adequate PSHE just as in the same way as if it did not have adequate mathematics or English.[103]

88. However, here Ms Bramman identified a key problem with PSHE, which is that although DfES may take PSHE as seriously as subjects like mathematics or English, many schools simply do not, because unlike mathematics or English it is not a statutory part of the National Curriculum on which pupils, and therefore schools, are assessed. OFSTED's concerns largely reflected the evidence we received about SRE and PSHE in our previous inquiry, and these could be rectified by establishing PSHE, including SRE, as a statutory and assessed part of the national curriculum, as we recommended in our previous report. When we put this to Ms Bramman, however, she replied that DFES had no intention of making PSHE statutory.[104]

89. We are disappointed that, despite a report from its own schools inspectorate stating that a major weakness of PSHE is its current lack of assessment, and the fact that it is often afforded insufficient time and priority within the school curriculum, DfES is unwilling to make PSHE and SRE a statutory part of the national curriculum. The costs and consequences of this ill considered decision are considerable. We again recommend the establishment of PSHE and SRE as statutory and assessed parts of the National Curriculum.

4 Department of Health, National Strategy for Sexual Health and HIV, 2001 Back

5 For example, HA27, para 2.3, HA04. Back

6 HA04 Back

7 HA04 Back

8 HC Deb 13 December 2004, col. 969W, Commons Written Answer Back

9 HA13, para 3 Back

10 Q40 Back

11 HA27, para 16.1 Back

12 Appendix 31 Back

14 HA27, para 16.2 Back

15 Sexual Health, para 110 Back

16 Choosing Health, para 84, p147 Back