British Association for Sexual Health and HIV President Dr Claire Dewsnap says the move to local government caused huge upheaval for services. But she believes while there are still issues that need fixing, the changes were worth it.
Of all of the different services provided by public health, sexual health could make the claim for having the most painful transition.
Services were almost entirely co-located and co-commissioned in the NHS prior to 2013. Now commissioning is split across different commissioners with councils responsible for STI testing and treatment and HIV prevention. But HIV treatment rests with NHS England and abortion, vasectomy and gynaecology services with the local NHS.
British Association for Sexual Health and HIV President Dr Claire Dewsnap said: “It was a very, very big change for us. Lots of people in sexual health were very worried – they could see it was going to cause fragmentation. The problem is it was never planned for or acknowledged. It was like no-one foresaw it and it was just introduced – pathways were split up overnight.
“In some services you had the same clinician doing treatment for STI and HIV. In quite a few situations they left the NHS – Tuped across – to run the council STI service. It meant the HIV service was left a shell and people were left scrabbling to find solutions. New pathways have had to be developed.”
Why STI rates have risen
Dr Dewsnap said this has had consequences, pointing to the rise in STIs with data showing record high levels of gonorrhoea and syphilis being recorded in 2022.
“The rise is partly to do with changes in society and other factors, but access to services is no doubt also part of it. It is taking people longer to get assessed and treated and the amount of outreach we can do has declined.
“Of course, funding has played a part. The cuts to the public health budget have been really challenging and will have had the biggest impact, but the ways services were split up certainly has not helped.”
Dr Dewsnap is also worried about the quality of sex and relationships education too. “It has suffered. We used to work with agencies and charities which would go into schools to deliver lessons – but now schools are just forced to do the bare minimum with funding constraints cited as the cause. These agencies would be signposting as well as raising awareness – they were an important of the sexual health family.
“We now have a generation that do not have the education about good sexual health like others have in the past. They are taking risks. We perhaps need a national awareness campaign.
HIV work an ‘incredible success’
But while STI rates have started to rise, new HIV diagnoses are falling. Dr Dewsnap calls this an “incredible success” with the rollout of HIV therapy PrEP now playing a major role.
“What has happened with that is testament to the advantages of what the move to local government has brought. They are able to work within communities with trusted partners to encourage people to come forward for PrEP.
“It is something the NHS would have struggled to do and rates of new HIV cases are plummeting as a result. The impact on the individual and their health is huge. We are all very proud of what is being achieved, although there are still some inequalities in terms of access that need addressing, in particular for black women.
“So as we move to the 2030 goal of ending all new HIV transmissions we are faced with the harder-to-find groups. We need to be brave. The piloting of opt-out HIV testing in A&E is working well – only around a fifth opt out.
“We are seeing new initiatives to reach out to people, such as the introduction of STI and HIV testing via vending machines. But that does require resources and good online booking systems.
“However, we have made progress digitally. COVID-19 really forced the pace of change as we had to move to online ordering at the start of the pandemic.”
What needs to change
One area that has not changed however is the focus the NHS pays to prevention. “We need to get the health service more interested. It has no incentive – the system is set up to focus on providing treatments.
“The move to integrated care systems moves us into that sphere – but I do wonder if we need a review to really consider how it can be done and attach financial incentives to it. I am not entirely convinced we are going to get there.
“I have been training GPs for 20 years – helping them identify who and how they test. But we are still struggling with that. And there are still problems with the way systems are set up. Take LARC, (long-acting reversible contraception), we have a situation where if you want it for contraception you have to go to a sexual health service or some GPs.
“But if it is for heavy menstrual bleeding you go to gynaecological services. Areas are working to try to create a more integrated services, but it is difficult because of the fragmentation.
“However, while the move has not been without pain, I would say on the balance of things, I would do it again. Not everyone in sexual health will agree, but, yes, I think it has been a good move.”