What do cuts to services mean for sexual health in England?
In August of this year, local council leaders warned that the UK’s sexual health services were at “a tipping point”. Left severely bruised by seven years of austerity, central government cuts to local authorities’ health care budgets looks to be one of the final nails in the coffin when it comes to centres that offer STI checks and treatment, abortion services, and contraception.
The cuts come at a time when demand for services is at the highest it has ever been, rising by 25% to 2.46 million visits between 2012 and 2016. Evidence has shown repeatedly that long term investment in sexual healthcare has strong, positive effects on the general sexual health of the population.
In this instance, the government is making decisions that are unequivocally short-sighted – decisions that could even prove dangerous.
“In 2015, local councils saw their funds cut by 6% (£200m), and it is estimated that by 2020 a further 9.6% of cuts to their budget will take place,” says Dr. Helen Munro, a member of the Faculty of Sexual and Reproductive Health, and a locum consultant in sexual and reproductive health. “This is having the knock on effect that councils are reducing services to save money — and sexual health clinics are one of the areas where funding has been dramatically cut in order to make savings.”
Yet these savings will clearly only be short-term savings. “In the long run we predict an increase in unplanned pregnancies and complex sexual infections, with related costs,” adds Helen.
In fact, a 2015 report from the Family Planning Association (FPA), entitled “Unprotected Nation”, which estimated the financial and economic impacts of restricted sexual and reproductive health services, forecasted serious cost implications for the NHS if unintended pregnancies were to increase.
“If current access to contraception worsens, over the 2015-2020 period the expected increases in healthcare expenditure is estimated to amount to an additional £1.178 billion in health service costs,” Helen points out.
The effects of cuts to service is already something that Helen is seeing personally through her work in the sexual health services, and she fears for the future.
“I think what we’re going to see is that an inequality of sexual health services will emerge,” she says, noting that there will be a divide between those who can pay for services privately, and those who need public services the most. Those, for example, for whom English is not their first language, or who can’t pay for a bus fair to travel to their nearest clinic.
“This is the very stark reality that I experienced in north London,” says Helen. “It was a divided community, split between the affluent and the very needy, and, in the parts of London where there is the most poverty, this is where services are closing down.”
Services in these areas are becoming a skeleton, nurse-led service offering very limited screenings. Yet patients have a huge, and widely varying range of needs, and they are simply unable to access the full range of contraception choices, and expert skills of specifically-trained doctors.
As a result of closures, Helen believes we will begin seeing increases in sexual infections, and antibiotic resistance, as well as unplanned pregnancies. “We’ve just got to the point where we have seen unplanned pregnancy figures go down in under 16s for the first time, but now patients are not going to be able to access contraception,” she says, adding that all the evidence is pointing to the prevalence of STIs increasing.
In July of this year the Royal College of General Practitioners (RCGP) released a report discussing the “perfect storm of factors” that will reverse advances made in the area in recent years.
The report highlights the advances made in reducing teen pregnancy and increasing uptake of Long Acting Reversible Contraceptives (LARCs) over the past decade, but adds that syphilis and gonorrhoea are on the rise, as is the number of women under 40 seeking abortions.
These factors, combined with a reduction in services due to cuts, are, in turn, putting GPs under intense pressure.
On top of this, GPs are finding it harder to access the training they need to be able to provide patients with effective forms of contraception. In fact, payments to GP surgeries for giving patients LARCs no longer even cover the costs of administering them.
Helen Munro points out that GPs used to be the first place people went to for sexual health advice. “I think patients are still wanting to access their GPs for help, but they are actually unable to get appointments with GPs, so end up coming to us instead,” she says. GPs are being pushed to the limit and simply no longer have the capacity to see patients for provision of contraception.
“People have, therefore, being relying on STI clinics to support them,” Helen adds. “But if they’re not there, I have no idea where these patients are going to go in the future.”
Part of the problem, the RCGP report notes, is the “fragmented commissioning” in England which came in with the 2012 Health and Social Care Act, which is generating avoidable costs and causing problems with patient choice.
One paragraph of the report is particularly chilling: “…SRH provision as a whole is at risk of collapse. By the time this downturn is more fully reflected in official figures these problems will have become entrenched and now difficult to reverse.”
Over the past two decades, comprehensive, easily accessible sexual health services have done huge amounts to bring down rates of teen pregnancy, rates of most STIs, and provide comprehensive family planning advice and contraception to the sexually active population of England.
And it is not just the provision of services at its most basic level that is being affected by closures to services. “There needs to be an idea that we provide holistic care, we want to be able to provide holistic care to our patients,” says Helen.
“Patients often have multiple needs and if we are trained to deal with those needs, we should be able to work without constraints put in place by commissioners. I think many doctors are becoming quite demoralised that their skills are not being used because of these constraints.”
Instead, many of the closures we are seeing have come as part of a planned switch from face-to-face consultations to online services, yet delays to online services have meant that people are being denied the care they need.
One proposed self-testing scheme was supposed to be rolled out across the majority of the London’s boroughs from the beginning of May, but due to delays it is not expected to start until January at the earliest.
Self-testing schemes and online diagnoses are not without their problems, even when they work as intended. “Moving to online or digital provision of contraception and sexual health services will only work for some, and our argument is that patients need choice,” says Helen. “They need to be able to visit trained health professionals close to their home, school, or place of work.”
For those with complex health needs, or difficult social and financial circumstances, sexual health clinics must be easily accessible. Their closure, and cuts to local authority budgets will only serve to create, says Helen, “an unfair and inequitable delivery of a key element of our public health in this country”.