Sexual health services on the brink
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5395 (Published 30 November 2017) Cite this as: BMJ 2017;359:j5395
- Caroline White, journalist, London, UK
- carolinew_health{at}hotmail.com
Unlike the NHS, local authorities, which have been responsible for public health in England since 2013, are not allowed to run into debt. Sexual health services, including contraceptives and testing and treatment for infections, account for about £600m (€680m; $790m)—almost a fifth of their public health spend (£3.4bn in 2017-18). But a succession of cuts in funding from central government have squeezed budgets, forcing councils to work smarter to avoid reducing services.
The BMJ sent freedom of information (FoI) requests about sexual health service provision and spending over the past three years to all 152 commissioning local authorities, 147 of which (97%) responded. Only 33 said that they had not reduced spending in any given year, whether by making efficiencies, through direct cuts to services, or because of natural variations in demand; 50 had done so in one year, 37 in two, and 27 in all three years.
Most of these annual reductions in spend were between 5% and 10%, but they ranged from 0.4% to 23%, the FoI responses show. And it’s likely that councils have now explored all viable options to contain costs.
The government public health grant, out of which sexual services are funded, has been steadily cut since 2015. It had an unscheduled 6% cut (£200m) in 2015-16. Scheduled annual cuts will amount to 9.6% by 2020-21.
Rising demand
These financial pressures have accompanied rising demand. Visits to open access genitourinary medicine (GUM) clinics that councils are mandated to provide rose by a third, from 1.6 million to 2.1 million, between 2011 and 2015,1 with some local authorities reporting 6% increases a year.
Although official data show 4% fewer new cases of sexually transmitted infections in 2016 than in 2015, the incidence of syphilis rose by 12%, from 5281 to 5920 cases, the most reported since 1949. New diagnoses of chlamydia fell by 2% from the year before, to 202 564 in 2016, but the number of people tested fell by 9%.2 Chlamydia screening was one of the services most restricted, the FoI responses show.
They also show that councils have adopted strategies to reduce overheads and increase efficiency. These have included integrating services, consolidating providers, partnering other commissioning bodies, and online provision.
And in areas of high demand, such as big cities, there has been a shift to fixed sum (block) contracts with service providers rather than payments for activity, which has reduced costs. But these re-tendered contracts, worth up to a fifth less and often incorporating further annual efficiency savings, shunt responsibility for rising costs to providers.
Isle of Wight council said that it had failed to find a provider for its new three year integrated services contract: it had slashed the budget by nearly 17%, to £800 000, with the intention of reducing it to £500 000 in year three of the contract.
Mark Lawton, spokesperson for the British Association of Sexual Health and HIV and a consultant in Liverpool, fears that all this will leave clinics with no option but to turn patients away.
“The cases we are seeing now are more complex,” he explains, citing “chemsex” as an example.3 “They take more time and need more specialist expertise. But how do we support that in an open access service on a fixed sum?” he asks. “The only way is to stop people coming in.”
Looking for solutions
Norfolk County Council is diverting symptomless patients, who account for 30% of attendances at its walk-in clinics, to an online service that provides test kits by post. Patients receive results by text message.
“Activity figures in eastern England are going up and up. If we carried on as before, we would be in trouble,” Tracey Milligan, sexual health commissioner for Norfolk Public Health, told The BMJ. A pilot of the online service was popular with patients, cheap to run (£9 per patient), and picked up three undiagnosed HIV infections. It has now been expanded across the county.
London’s populations are highly mobile and rates of sexually transmitted infections are 65% higher than elsewhere in England.4 Twenty nine of its 32 councils have also gone digital for symptomless patients, creating a centralised e-portal that is due to go live in January 2018 and common quality standards for care as part of the London Sexual Health Transformation Programme, coordinated by the City of London.
And they have adopted standardised payments to tackle the perennial frustration of cross charging, whereby councils pay when their residents use the often costlier sexual health services in other boroughs.
FoI responses indicate that some councils estimate this alone could save them as much as £2m. The whole programme could save London as much as £27m over the next 3-4 years, a spokesperson told The BMJ.
Vulnerable budgets
Budgets were raided when sexual health services were run by the NHS. But a report published earlier this year by think tank the King’s Fund suggests that recent cuts are deeper and more detrimental than before.5
“Overall, local authorities have managed huge cuts very well, and the clinical side is holding up,” King’s Fund senior fellow David Buck told The BMJ. “But it’s what you don’t see in the numbers—restrictions and closures—so that even if a service doesn’t disappear, it’s diluted.”
Nearly two thirds (87) of respondents to The BMJ’s FoI requests said that they had not cut services, but 21 had “rationalised” GUM or community health clinics, while nine had reduced contraceptive services. Thirteen had reduced services for HIV support or care, and 23 had cut those for prevention or promotion. Other targets for trimming costs included psychosexual counselling, outreach for vulnerable groups such as sex workers, and school drop-in sessions.
“The fat has already gone,” emphasises David Buck. “Many local authorities have already recommissioned their services so they have got all the efficiencies they are going to get and will have to make real cuts [to services]. We are about at the limit now, and in some places have gone beyond it.”
A commissioning lead for one London local authority, who asked The BMJ for anonymity, agrees. “We don’t believe we can do any more ‘salami slicing,’ and any further cuts would have to be to actual services.”
An uncertain future
Other uncertainties pepper the horizon. The statutory ring fence on public health funding from central government will lift in 2019. And the government wants councils to fund public health from their business rates by 2020, although this wasn’t mentioned in the Queen’s speech.
“I’ve not seen any credible plans for introducing such an initiative,” comments Louise Smith, director of public health at Norfolk County Council. But the possibility is affecting budgeting. “Finance colleagues can’t tell me what assumptions I should make about the size of the allocation: so we need to make three to four year forward plans on guesswork,” she explains.
So are sexual health services better off under local authority rather than NHS control? Buck thinks the changes have prompted innovation and modernisation, such as digitisation, a focus on outcomes and better value for money, and the integration of services, but that “significant issues” in terms of funding and patient care, are now beginning to emerge.
Services under the NHS also had problems, beset with “huge inequalities” in access and funding decisions, and didn’t measure spend, he emphasises. “It’s a mixed picture, and not all bad, but no one was expecting this level of austerity,” he contends.
Fragmented HIV care
The 2012 Health and Social Care Act, which transferred public health to local authorities, split responsibilities for sexual health.6 This has created commissioning and funding anomalies and fragmented care for patients, particularly those with HIV.
Local authorities are responsible for prevention and testing, but NHS England and clinical commissioning groups fund testing in services they commission. And treatment falls to NHS England.
Most recently, these ambiguities generated a legal battle between NHS England and the charity the National AIDS Trust (NAT) over who should pick up the tab—estimated to be around £20m a year—for pre-exposure prophylaxis (PrEP) for people at high risk of HIV infection. The indications from some London HIV clinics are that its use is linked to a downturn in new diagnoses,7 and preliminary figures from Public Health England indicate an 18% fall in new diagnoses to 5164 in the UK in 2016.8
NHS England argued that councils should foot the bill, as PrEP falls under prevention. But NAT insisted they couldn’t afford it, and that NHS England should take this on under its specialised commissioning remit. NHS England lost the case and has now agreed to fund a three year pilot to inform routine commissioning of PrEP.
Historically, HIV treatment has mainly been provided by NHS GUM services, which local authorities now commission. This has led to what Yusef Asad, director of strategy at NAT, describes as “a parting of the ways” when local authority contracts have gone out to tender, “with HIV clinics finding themselves either without a host [provider], or remaining but with no wrap-around support [such as testing for sexually transmitted infections or social support services], or closed altogether.”
And “various attempts to get the two bits of the system to commission together have been very inconsistent,” he adds.
Steve Taylor, executive committee member of the British HIV Association, which represents professionals, highlights “a terrible tendering fiasco” in the Midlands, where the tender went out three times and consultant numbers had to be halved to cut costs, as well as examples of clinic closures in Leicester, Warwick, and Birmingham.
“There are big implications for public health, and staff find themselves being put in really difficult positions, trying to maintain stability for patients,” he laments, foreseeing similar problems for London, where all such services have been retendered.
The experience of would-be patients at London’s Dean Street sexual health and HIV clinic seems to bear out his prophecy. The closure of several other clinics in the capital “is impacting on our service,” it told patients, “With over 1500 patients daily trying to reserve approximately 300 time slots.”
Challenging and complex
Smaller HIV services, which may run only one weekly clinic, are finding it particularly difficult to get support, says Taylor. “HIV services are seen as a bit more challenging and complex, and not a good way of covering costs, so providers don’t want to touch them.”
Rural areas also pose challenges: Herefordshire nearly lost all its HIV services, he adds. Patient numbers may be small, but the implications aren’t, he suggests. “If local services are closed people may not travel to find alternative care. And we currently have fantastic rates of retention—90%—after diagnosis.”
Local authorities also commission non-clinical services to support the wellbeing of people with HIV. But these aren’t mandatory,9 and NAT found that council spend on them had fallen by 28% from 2015-16 to £4.4m in 2016-17, confirming anecdotal evidence it had received of moves to decommission them to save money.10
This is despite their recognised importance in helping people with HIV stick to treatment plans and in bolstering their mental health: the suicide rate for HIV positive men within the first year of diagnosis is more than five times higher than that for men in the general population, research suggests.11
About a third of the estimated 101 000 people with HIV/AIDS in Britain are now older than 50,12 but many services are not designed to deal with HIV as a long term condition.
“[Treating] the disease has moved on massively in terms of pharmacology and medical care, but not in terms of social issues and stigma,” argues Yusef Asad. “GP knowledge and understanding about HIV is very poor: but that’s not surprising as they get little training on it and it’s mostly about infection control. There are wider issues about making the whole of the NHS HIV literate.”
Patient view: Cuts make HIV services impersonal
Rory Kilalea, HIV services user, Oxford
I was diagnosed with HIV 15 years ago. I’m an older chap, and like many others in my generation who are living with HIV, I do get affected by loneliness. My partner died three and a half years ago.
Because of the cuts to councils and NHS, mainstream services have become impersonal and you can feel like a digit or a cipher. It’s a real downer for me and anybody of an older age. The people working in these services aren’t to blame, of course—they’re stressed enough, but they just don’t have time to care, let alone to have a full understanding of HIV. You end up having to disclose your HIV status to different people over and over again, there’s no continuity of knowledge.
There’s also no guarantee that they will have an up-to-date understanding of HIV. I am open about my HIV status and sexuality, but I see stigma all the time. I still get an odd reaction from a dentist and places like that when I say I have HIV. There’s a pause. Nothing is said, but the pause, the feeling of discrimination is there. I am undetectable medically but not emotionally.
That’s why stigma has to be addressed before we can use mainstream services. We need services run by people who genuinely understand HIV.
Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I work part time doing public relations for BMJ and am a lay member of Waltham Forest Clinical Commissioning Group.
Provenance and peer review: Commissioned; not externally peer reviewed.