Sexual health
Authors: M. Adler
Journal: BMJ (2003)

The House of Commons Health Select Committee has published its inquiry on sexual health and highlighted a major public health problem and increasing crises.1 One hundred and sixty three written submissions were received, 67 witnesses gave evidence during the course of 10 sessions, and the committee visited north east England, south west England, Sweden, and Holland. The tone and recommendations of the report left no doubt about how concerned the members of parliament were by what they had heard and seen for themselves.

The report covered the trends and services for sexually transmitted infections, including HIV; contraception and unwanted pregnancy; sexual behaviour; and sex education. The picture is of a continuing decline in the nation's sexual health, with services unable to cope and an increasingly demoralised but willing workforce. The committee heard that all sexually transmitted infections had increased in England over the past six years, particularly new cases of gonorrhoea (86%), chlamydia (108%), and syphilis (500%). They also heard that two chlamydia pilot studies conducted in the Wirral and Portsmouth showed a prevalence of approximately 10% in women under the age of 25. Not surprisingly, the increases in infections have resulted in a doubling in attendances at departments of genitourinary medicine within England in the past 10 years, which have reached 1.1 million cases a year.

The annual total of new HIV diagnoses increases each year, and in conjunction with the success of anti-retroviral therapy the pool of infected people is increasing, with implications for treatment costs and dangers of transmission. Apart from infection, teenage pregnancy rates are declining slowly and steadily, the committee heard, and 79% of women having abortions are beyond their teenage years. Add to this the nation's changing sexual behaviour over the past 10 years–decline in the age of first intercourse, increase in total number of lifetime partners and concurrent relationships, a decline in safe sex practice, particularly among homosexual men–and finally, the evidence from young people to the committee that sex and relationship education is patchy, too little, too late, and too biological. All of this gives us a pressure cooker situation.

Evidence given on the committee's visits to services confirmed and underlined that the heavy burden of infections, unwanted pregnancies, and high risk sexual behaviour was putting increasing pressures on existing services–for example, departments of genitourinary medicine have found it hard to deliver immediate, high quality, open access and self referral services. The length of waiting time has increased within the United Kingdom from five days for men and six days for women in 2001 to 12 and 14 days respectively in 2002. In a third of clinics patients had to wait longer than four weeks for an appointment. One clinic indicated that each week more than 400 patients attempting to make appointments by telephone were refused. The Department of Health's Monk Report of 1988 set a target that all patients should be seen within 48 hours.2 Sexually transmitted infections are communicable diseases, and delays in access can result in complications and onward transmission and in sexual partners not being identified promptly.

This worrying picture of increasing infections and case loads, services in crisis, poor access, and inequalities was added to by a picture of poor facilities and under staffing. The picture in genitourinary medicine is of low consultant numbers. In contrast to the Royal College of Physicians' recommendation of 1 per 119 000 of the population, some parts of the country had ratios of 1 per 400 000. At a national level, using the recommended ratio, the shortfall was calculated at 173 consultants–or the need for a 93% increase on the current 247 (238 whole time equivalent) in post. Unless new posts are created, about 35 specialist registrars with certificates of completion of specialist training will not obtain posts over the next two years in England. A quarter of consultants are singlehanded, and 30% of clinics were open three days or less per week, with some districts having no service at all. Surveys presented to the committee showed that many clinic facilities were so poor that 80% required refurbishment and extensions and, in some instances, new facilities. Committee members saw for themselves the airless basements and Portakabins and heard of clinical rooms without sinks.



Summary of main recommendations of report on sexual health

Prevention, education, user involvement



Each primary care trust to establish a patient forum or seek views of service users


Support voluntary work at a local and national level


Training in primary care and establishment of sexual health networks


Sex and relationship education to become a core part of national curriculum






Standards, targets, surveillance



More comprehensive surveillance system(s)


Patients attending departments of genitourinary medicine to be seen within 48 hours


National service framework to be established for sexual health


Sexual health and HIV to be included in local delivery plans and strategic health authorities to use standards to manage primary care trusts' performance






Services

Genitourinary medicine, HIV



Urgent review


Manpower requirement and expansion of consultant posts


Additional and recurrent revenue commitment £22-30m a year to be allocated specifically to these services


Improvement of clinic facilities and premises


Chlamydia screening to be rolled out more rapidly and suboptimal tests to be withdrawn in favour of molecular amplification tests


Encourage development of clinical networks for both sexual health and HIV and commissioning consortia


Department of Health to review access to anti-impotence treatments and include sexual dysfunction in wider sexual health strategy






Contraception, termination of pregnancy



Contraceptive services to be prioritised


Government to facilitate open access for termination of pregnancy and early medical abortion in a wider range of health care settings








For community contraception, the picture of a shortage of specialist consultants and senior staff was similar, and closures of clinics seemed to be an easy option when money was required for other services. The service was branded a poor cousin, with inequalities in the range, quality, and accessibility of service provision across England. Abortion services were reported as being no better. The percentage of abortions funded by the NHS varies between 46% and 96% in different parts of the country, and women can wait up to six weeks for a termination.

The sexual health and HIV strategy was welcomed by witnesses, but considerable concern was expressed about the inadequate resources and political leadership given to it and the problems of implementing the strategy at a time of such change within the NHS. The committee was presented with evidence that over half of primary care trusts questioned had not agreed a process for implementing the strategy, almost two thirds had not completed an up to date needs assessment, more than a quarter had not included sexual health and HIV in their service and financial framework, and almost a fifth of primary care trusts had no appointed lead for sexual health.3 Clearly, since sexual health is not an NHS priority or a national service framework, it has no local clout, leverage, or profile. Without this profile and performance management, the minister's belief that primary care trusts will find “extra funding through their mainstream budgets to modernise, improve, re-engineer and almost re-energise the whole sexual health field” is unrealistic.4

The select committee has made a series of far reaching recommendations to deal with this major public health problem (box). It is hoped that the government will act on them and listen to the words of the committee's chairman, David Hinchliffe: “The whole committee has been frankly shocked and appalled by some of the evidence that we have received... the whole sexual health service seems to be a shambles.”