Health Service Focus

19.11.15

Sexual health commissioning decisions are being driven by money, not quality

Source: NHE Nov/Dec 15

Dr Anne Connolly, chair of the Primary Care Women’s Health Forum, vice-president of the FSRH, and member of the Royal College of GPs’ Sex, Drugs and Blood-borne Viruses Group, speaks to NHE’s Luana Salles.

Dr Anne Connolly2Commissioning for sexual health services first became fragmented in 2012 with the introduction of the Health and Social Care Act. Waves of mammoth commissioning reforms pushed specialist services – specifically, outreach contraception and sexual health (CASH) services – from primary care to public health, now managed by local authorities. The money and responsibility for core contraception providers in general practice, however, such as for pills and injections, was left with NHS England. 

The consequences of “everything going pear-shaped” soon landed on CCGs, though contraceptive services fall outside the traditional remit of their work, and on councils dealing with public health. This disjointed nature of sexual health services, and the consequential commissioning silos, means they are not entirely ring-fenced like the rest of the health service. With looming £200m cuts to public health budgets expected for this year, for example, many sexual health services will be further reduced, restricting access to specialist contraception clinics. As a result, women are increasingly forced into GP practices – where, unlike in contraception clinics, anonymity cannot be retained – in search for contraception that should have been available in more reliable and long-acting forms within specialist services elsewhere. 

Dr Anne Connolly, vice-president of the Faculty of Sexual & Reproductive Healthcare (FSRH), part of the Royal College of Obstetricians and Gynaecologists, told NHE: “Not being able to access a reliable method of contraception easily really compromises those who are most vulnerable, such as our teenagers, women who don’t speak English as a first language or those who don’t know how to navigate the complexities of healthcare. 

“Women who have private transport will be able to access a service 10 miles away, whereas youngsters or people who don’t have money will end up either not using any contraception or will go to their GP, who may or may not be able to provide long-acting reversible methods (LARC). Therefore, women will end up with less reliable pills and injections.” 

Priority shift 

But even among women who can see their GPs for contraception or feel comfortable doing so, not all of them will be able to receive it. As Connolly pointed out, primary care is increasingly pushed for appointments, with GP workloads and the quality of care taking a hit. Naturally, growing demand has also forced the front line to prioritise, and sexual health is far from top on healthcare’s priority list. It instead faces the prospect of becoming another Cinderella service. 

“The priorities of primary care on the whole are managing long-term conditions and reducing appointments for A&E,” Dr Connolly said. “So priorities now are not necessarily about taking on a lot of extra work that they haven’t previously taken on.” 

Knowledge gaps 

While this shift towards long-term management as a result of an ageing population is understandable, sexual health services cannot survive without considerable expertise. “Reproductive health is an incredibly complex area of healthcare to commission correctly, mainly because of this understanding of the importance of LARC and their effectiveness, but also the complexities of the population who are most at risk,” Dr Connolly said. “Commissioning decisions [for] clinical services are made by people who don’t fully understand that. They’re increasingly being made, and we can understand why, for financial reasons rather than for quality reasons.” 

The availability of nursing staff equipped with the necessary tools to handle contraception services is also narrowing, she added. Over the years, access to training courses for nurses became increasingly constricted, with many being sent on long-term condition courses because “that’s where the money is for primary care”. As a result, much of the sexual health work carried out in primary care currently is delivered by nursing staff that haven’t had sufficient training, or at least not as much as they would like. 

One idea is co-training courses between councils and GPs, but Dr Connolly said there has been an ‘us vs them’ approach to merged training, with some services reluctant to do training in the primary care sector because of fears that more of the already-limited funding will go to general practices, not specialist areas. 

“There’s always that uncertainty about other people doing services, and whether that takes money away from your own services to train other people,” she said. 

Adding insult to injury, clinical staff are left in the dark when it comes to primary care contraception access – because no-one is really measuring the quality or quantity of these services. “There is no good data about what’s going on in primary care,” Connolly explained, “so some women are just being bounced around from one service to another, and then we’ll go back to playing Russian roulette.” 

Social costs of pregnancy 

The implications of broken sexual health services will be far-reaching, with healthcare experts already predicting tens of thousands of extra cases of sexually transmitted diseases and an influx of antibiotic-resistant infections in the next five years. But within the contraception realm, Connolly said, all forms of social spending will skyrocket. “The implications of an unplanned pregnancy are often on health because of abortions costs, and the woman may not have optimised her healthcare prior to becoming pregnant, [she may be] smoking or overweight. But the social implications are also huge,” she told me. 

“There is this whole social impact of a teenager becoming pregnant and what that does to her social outcomes, cost of housing and extra cost of education. There’s a massive social cost that’s not being seen. Saying ‘we’re going to cut 50% off the contraception budget’ is very short-sighted when you think about the longer-term social implications of that. It’s all about the silo of commissioning.” 

At the other end of the spectrum, a growing number of women are delaying childbirth until their 30s – resulting in around 15 years during which highly fertile women need good contraceptive access. “We also know that more women are changing partners when they are in their 40s, and that group is being totally ignored by the priorities of public health,” she added. 

Funding hole reaches £8bn 

Contraception relies on more than just adequate funding to survive; integrated commissioning, prioritising, data collection and extensive staff training are all vital pillars. But these pillars will collapse without sufficient money. 

“Funding cuts will affect the provision of services (as in where the clinics are), reduce the number of clinics and reduce the number of trained clinicians, which then goes on to reduce the number of consultants,” Connolly said. 

And this year’s Unprotected Nation report, released just after our interview, clarified the estimates: as a direct consequence of budget cuts, the extra cost to the public purse of unplanned pregnancies and sexually transmitted diseases could surpass £8bn over the next five years, plus an extra £1.7bn in education costs. If this reduced spending becomes the norm, every £1 cut could cost the country another £86 down the line. 

When the government turns its back on the issue of contraception, it is in fact only betraying its own rhetoric about easing GP workloads and supporting frontline staff. 

As Connolly put it: “We’re looking with so much concern about what’s happening with specialist services, that actually we are still not really understanding the implications on primary care workload and the quality of care provided there.” 

This pattern of false economies seemed to be mirrored in the social care sector, where reducing funding would only drive the elderly to A&E services already filled to the brim with patients. “It’s exactly that same conversation,” she confirmed, bringing up the case of Manchester, where a £6bn health devolution deal is being steered by talks of cross-agency service integration. “It’ll be interesting to see what they come up with, where they put it all together. It’s so uncertain, isn’t it? But I think we’re all watching that space.”

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