Mission position

Primary care trusts are failing to tackle sexual health needs, and the consequences are serious for patients - and budgets.But before progress can be made, commissioners need to address a dearth of data on what is required. Emma Forrest reports

As sexual health and HIV commissioner for Brighton and Hove and East Sussex, Graham Taylor is by his own admission a rare animal.

He estimates there are fewer than a dozen commissioners dedicated to HIV and sexual health in England.

There lies the rub. There is an increasing realisation that if sexual health is to reverse increases in rates of sexually transmitted infections, it must cease to be an issue that is only dealt with when someone presents at an overstretched genito-urinary medicine clinic. Instead, lifestyles and behaviour should be altered to reduce the possibility of contracting an infection in the first place.

'The [national] sexual health strategy was put together with the best of intentions, but there are serious problems at primary care trust level, ' says Terrence Higgins Trust policy director Lisa Power.

'Many do not have the specialist expertise or do not see it as a priority.

They are only concerned with what will or will not help them reach national targets.'

As PCTs are reluctant to take on the financial burdens of immediate care, long-term benefits in cost savings need to be recognised. For while each HIV patient brings with them a massive drugs bill, the savings made in not having to treat them for other conditions later are at least£250,000. Also worth considering are the long-term (and often hidden) health implications of sexually transmitted infections, which threaten to be very costly for the NHS. It builds a compelling picture for prioritising sexual health. But one difficulty is establishing what those accessing current services actually need.

While HIV patients have long-term needs (and the costs that go with them), visitors to a sexual health clinic may only attend once. Nor is there any obligation to visit a local clinic; as most have an open door policy, patients can travel from any distance and are under no obligation to provide clinics with personal information.

It can therefore be difficult to build a profile of an area's sexual health needs.Mr Taylor argues that establishing such data is essential before services can be improved.

'Information-gathering systems are key to raising the profile of sexual health. It is no good just asking for more money; you have to understand what the data you have means for your commissioning needs.'

This is not made any easier by public reluctance to use GPs for sexual health services.Ms Power points out that if GPs offered the same levels of confidentiality as GUM clinics, more people might seek help from them. She attributes this in part to the stigma associated with sexual ill-health and the lack of public information on positive promotion of sex education.

'There are no support groups for gonorrhoea - only for incurable diseases, ' says Ms Power. 'Sexual health clinics have the worst premises in hospitals; that needs to be tackled by services.Meanwhile, while in the 1980s there was information everywhere, now it has to be brought back to where people have access, such as in soap storylines and being talked about on daytime television.'

Though clinics are kept confidential, information that could be gathered includes how many people attend, how many appointments they have and keep, what conditions people have and where they come from. Patients' provenance is key as it is not unusual for GUM clinic users to cross PCT borders to use services in order to avoid bumping into anyone they know in their local area.

'If it is known where someone is travelling from, then their PCT can be billed, ' adds Mr Taylor.

He suggests that, as with his own position (commissioning for nine PCTs), expertise in sexual health should be made the focus of a commissioner within a consortium of PCTs, rather than squeezing it in with commissioners' other responsibilities.

Equally, acute clinics should engage with primary care providers to work on preventive measures.

'One extra consultant in a clinic will relieve the pressure, but we need to think about how people are getting sexual ill-health in the first place.Making this work requires a lot of lateral thinking, ' admits Mr Taylor. 'The sexual health strategy is a very medical model.Health promotion workers, youth services and voluntary services all need to work together. If a school does not want to provide a drop-in centre, then we need to think of another way to provide it.'

Further information lwww. tht. org. uk lwww. doh. gov. uk/sexualhealthandHIV/index. htm 'Purveyor of filth': breaking the silence on sex education 'Teachers are not trained to talk about sex and they do not want to, ' says Terrence Higgins Trust policy director Lisa Power.She points to a worrying lack of knowledge about sex and sexually transmitted infections among teenagers that is not being alleviated by adequate sex education in schools.

'Working with schools is problematic, 'says Brighton and Hove and East Sussex sexual health and HIV commissioner Graham Taylor, with masterful understatement.'I've been called 'a purveyor of filth'but all I am giving young people is access to the information they need.The level of knowledge about sex is pretty poor and I do not see how telling someone that they can get pregnant standing up is a bad thing.'

The issue of how much sex and relationships education should be provided in schools arises because it is not dictated by the national curriculum and is instead left to the guidance of school governors and the head teacher.Their attitude will affect how an entire school approaches the subject in both formal and informal ways, while parents still have the right to withdraw their children from any formal lessons.Nor is sex education part of teacher training programmes.

'There are some schools where it has been accepted as a priority.But many schools do not offer any sex education. It is traditionally seen as such a controversial subject that it is the last bastion that teacher training has not dealt with, ' says Sex Education Forum co-ordinator Anna Martinez.'But we are getting there.There are more and more schools working in partnership with other services.This should be about young people's needs.Sexual health does not have to be bad - a taboo subject - and schools have a part to play in promoting that.'

'Teachers, doctors and social workers need to talk about sex, 'adds Ms Power.'Because if they will not, who will?'

Key points

Many primary care trusts do not see sexual health as a priority, preferring simply to meet national targets.

Genito-urinary medicine clinics do not have the capacity to attack waiting times.

Rather than just a medical model, health promotion workers, youth and voluntary should work together.