Published: 14/04/2005, Volume II5, No. 5951 Page 14 15
Sexually transmitted disease and teenage pregnancy rates continue to soar. Although the government is has thrown£300m at the problem, PCTs are proving slow to prioritise much-needed improvements to services. Helen Mooney explains
'There is a load of stuff I can be sacked for not doing but tackling sexual health is not one of them.' This candid admission from a primary care trust chief executive may not be what the Department of Health wants to hear, but it is the reality of sexual health on the NHS frontline.
The DoH says it wants PCTs to focus on five key areas to kick-start its implementation of the public health white paper. Modernising sexual health services should form a crucial part of their local delivery plans, says the government. So far, so good. But a plethora of surveys, reports and recommendations over the last two months point strongly to the fact that this message is not getting through.
Last week, HIV and AIDS charity the Terrence Higgins Trust published its annual survey on sexual health services in England.
Its findings leave little doubt that sexual health services are still one of the NHS's poor relations.
Admittedly the government has taken some note of evidence that shows ever-increasing rates of sexually transmitted diseases and teenage pregnancy. It has also invested£300m of non-ringfenced cash to pump-prime the extremely overstretched frontline battleground of sexual health services.
Yet the Terrence Higgins Trust survey suggests the reality may be lagging behind policy.
According to the survey, sent to all PCT sexual health leads, nearly a third of respondents said that HIV and sexually transmitted infections did not feature in their local delivery plans.
'Given that a PCT's LDP is the basis of its allocation of resources and a clear indication of what it is, and is not, concerned about in terms of local health, it is alarming and a matter for concern that around a third of PCTs surveyed did not think it worth even a mention in their LDPs, ' notes the charity.
Another stark finding is that nearly half of the PCTs questioned had spent the same or less on sexual health services in 2004 as they did the year before.
Sexual health leads at PCT and strategic health authority level know these figures all too well. But they also know of the constant battle to convince their management boards that sexual health needs to be a much higher priority.
PCT managers are far more concerned with balancing their books, meeting end-of-year targets - such as the six months maximum outpatient waits - and above all improving their performance in the league table of star-ratings.
This summer the Healthcare Commission will publish its final performance ratings for all NHS trusts based on the same formula as preceding years. The following year, trusts can expect a radically different system, although not so different that it is likely to contain a specific measurement for PCTs on sexual health service delivery.
This is despite the fact that the commission conducted a sexual health review and pilot over the last year, with the initial intention of feeding its results into the new ratings system.
The basis for the commission's new system or 'annual health check', published after a 12-week consultation last month, states that while the sexual health review will be taken forward to provide a national report on progress and best practice, the commission 'will not provide separate scores in the annual rating'.
Yet there is a growing clamour from the frontline for a government sexual health target that goes beyond the national 48-hour genito-urinary medicine clinic waiting time which PCTs must achieve by 2008. When the Terrence Higgins Trust asked PCT sexual health leads what would enhance their ability to make greater progress locally in reducing the incidence of HIV and other sexually transmitted infections, the response was clear.
'We want a specific government target for HIV/GUM, which does not exist currently, ' said one. 'Include sexual health in star-rating', demanded another. 'Sexual health needs to be a greater priority, ' said a third.
Dr George Kinghorn, a GUM consultant based at Sheffield Teaching Hospitals trust, is disappointed but not surprised that the Healthcare Commission has decided not to use its review to directly rate the NHS on sexual health provision: 'The NHS is currently a million miles away from achieving a true 48-hour access target for sexual health.' Dr Kinghorn's opinion is echoed by the Commons health select committee's recent update on new developments in AIDS/HIV and ERsexual health policy which concludes: '. . . evidence suggests that over the next three years, sexual health services will face a huge challenge in achieving [the 48hour target] from the current position, as problems with waiting times seem to have become even further entrenched since the publication of our [last report on sexual health in 2003].' The most recent figures from the Health Protection Agency audit on GUM waiting times published last November make depressing reading.
They show that only 38 per cent of those requesting an appointment at a GUM clinic were seen within 48 hours, and 26 per cent had to wait more than two weeks.
Dr Kinghorn contends that the real figures could be even worse.
'Many GUM clinics are offering a system of advanced access which means patients are only registered if they phone the clinic and an appointment is available for them within 48 hours. If not, they are not registered and are told to phone back the next day until an appointment becomes available. This is an absolutely immoral system.' Dr Kinghorn says that unless PCT managers are prepared to 'own the problem', the sexual health crisis will continue to worsen.
'If PCT managers do not think it is their problem, then they have failed to understand it is a significant public health problem.' He is appalled by the comments of chief executives who told HSJ that unless sexual health improvement becomes a 'hanging offence' it will not be taken seriously.
'This kind of attitude is at best unhelpful and at worst irresponsible, ' he says.
The assumption among more cynical managers and sexual health leads is that the government is afraid of raising public awareness and setting explicit targets because it knows the system would be stretched to breaking point and that the sexual health problem is far greater than has been admitted.
Prompted by concerns about the challenges facing GUM services and their capacity to respond effectively, the Medical Foundation for Aids and Sexual Health (MedFASH, an independent charity supported by the British Medical Association) was commissioned by the DoH last year to carry out a two-year national review of GUM services.
According to MedFASH, the review aims to 'undertake a multidisciplinary assessment of each GUM service in England, offer recommendations for service improvement to GUM clinics, PCTs and SHAs and provide findings and recommendations from the review to the DoH'.
The first phase of the review involved a written questionnaire sent to all GUM clinics in England last September. According to MedFASH, the data from the first 72 per cent of clinics 'gives the most up-to-date snapshot available of the state of GUM services around the country'. The health select committee's recent report says it is the 'only available source of such information, and the most accurate and up-to-date information about the state of sexual health services currently available'.
But here is where the waters muddy. MedFASH has now submitted its analysis to the DoH and is, according to the committee's report, 'happy for the data to be shared if the DoH agrees'. The DoH does not. The health select committee report states that 'the DoH declined to supply [the data], arguing that it was still 'work in progress'.' It continues: 'When we pressed the minister [Melanie Johnson] and the DoH official on this point, we were told they had only recently received the data, and ministers and officials had not yet had time to consider it.' According to the committee, Ms Johnson said that she had not yet 'received the information with advice from officials' [10 February] despite a memorandum sent by MedFASH in December 2004 indicating that it had already submitted the analysis to the DoH.
The committee's report expresses concern at the delay and highlights that committee MPs 'are surprised by the air of secrecy which surrounds this research, and can only surmise from this that it contains findings that would be unwelcome for the government.' 'It would seem counterproductive to withhold the most up-to-date information on sexual health services from the health committee when it is conducting an inquiry into precisely this subject'.
Whatever the findings of this data, the situation in sexual health services is critical.
Dr Kinghorn reiterates: 'There is no magic to this. PCTs need to engage in this and they need to own the problem.'
MEDFASH RECOMMENDATIONS: WHAT PCT S MUST DO
Access to services:
Service capacity must be adequate to address identified needs and to meet the stated time limits for access.
Integrated care pathways should be agreed, prioritising ease of access.
Open access to GUM and community contraceptive services is maintained.
Adequate STI and contraceptive services should be provided on each working day within a network area.
Information on services must be widely available, including for those who may need urgent access to care.
Activity indicators PCTs should include in their LDPs on sexual health:
The percentage of patients attending GUM clinics who are offered an appointment to be seen within 48 hours of contacting a service, aiming to reach 100 per cent by 2008.
The number of new diagnosis of gonorrhoea per 100,000 population.
The percentage of the sexually active population aged 15-24 accepting chlamydia screening.
The under-18 conception rate.