Baroness Joyce Gould
Posted 26th Mar 2013
Sexual health is an important part of physical and mental health. It is a key part of our identity as human beings together with the fundamental human rights to privacy, a family life and living free from discrimination. That was the underlying principle behind the first ever national strategy for sexual health and HIV in 2001. Over the ten years of the strategy advancements were made in the provision of open access, the integration of services, the promotion of good sexual health and the acceptance that sexual health was a fundamental part of public health.
Change of Government and a major restructuring of the Health Service included the return of public health, and therefore sexual health, to local government from April 2013. The transition process that followed has not been easy, with genuine concerns and anxieties about the complexity of the new commissioning process and the split in the commissioning of fundamentally linked services such as HIV treatment and care and HIV prevention and testing between different commissioning bodies.
After a long wait, the promised sexual health policy document – A Framework for Sexual Health Improvement in England - was published this month.
Not knowing what to expect, a number of local authorities had reportedly delayed their preparations for taking over the commissioning of sexual health services until publication of the framework – two years later than originally anticipated. This has left them little time to ensure all the necessary elements of service provision are in place from 1st April.
Further guidance has also just been issued on the commissioning of sexual health services, on the legal requirements and on best practice. The guidance stresses the importance of confidential open access services working to the current regulations; but there is no direction as to how the services should be provided.
But what of the Framework itself? It is a comprehensive analysis of the current position of sexual health in England; it acknowledges that sexual health affects everyone, it acknowledges the positive progress already achieved, it details where improvements and actions are necessary to improve sexual health outcomes and identifies the Government’s ambitions for the future.
Very specifically and importantly it prioritises prevention, and looks at sexual health for all age groups, at the integration of services commissioned by local government and at measures to address other key determinants of health and wellbeing such as health inequalities, alcohol, drugs, violence and mental health. It also details the new commissioning process.
While the Framework clearly sets out the Government’s ambitions for sexual health improvement, what it does not do is indicate any role for national government in the realisation of these ambitions. This will be the responsibility in the main of local authorities who will commission most sexual health services alongside the Clinical Commissioning Groups and the NHS Commissioning Board. The working relationships between these three bodies will need to be robust but also transparent in how their decisions are made.
It will be the responsibility of local government to provide easy and open access to confidential, non-judgemental, holistic sexual health services based on the needs of their community. Guiding progress nationally and locally will be Public Health England encouraging local authorities to make every effort to improve health services in their communities.
Two of the crucial sections for me are those dealing with issues that influence a person’s sexual health and sexual health through the life course. Sexual health across the life course follows the theme of the original strategy for public health, Healthy Lives, Healthy People, accepting that it is crucial that the differing needs of men and women at different stages of their life and of different groups in society are considered when planning services and interventions. It outlines the challenges, services, prevention interventions, and the wider linkages for each of the age brackets.
Up to the age of 16 years raises the important subject of sex and relationships education, the ambition being that all children and young people receive good quality sex and relationships education at home, at school and in the community. However, whilst there are fine words of intent, what schools include in their sex education programme is a matter for local determination. Maybe here there is a role for Public Health England. For the 25 to 49 age group, the framework concentrates on the provision of a full range of contraception for women of all ages, rightly pointing out how important it is to support people to plan and space their families and that restricting access to services by age can therefore be counter productive and ultimately can increase costs.
Long term health conditions that may cause sexual health problems, in particular erectile dysfunction and its consequences, and an ageing population living with HIV are highlighted for the over 50s. There is no reference however to care for the elderly with HIV, not only in the home but also later in life in care homes, with the necessary improved training for carers and staff.
Looking at the section on sexual health influences and prevention, the analysis of attitudes, beliefs and behaviours raises many interesting issues including an increase in risk taking and reduction in condom use, stigma and discrimination as factors in preventing early diagnosis, accompanied by the anxiety of disclosure to friends and families. Whilst there is reference to domestic violence under the paragraph on vulnerable groups there is no cross reference to those women subjected to domestic violence as a result of their having disclosed to their partners that they are HIV positive.
Advice for local authorities on how to change those attitudes and behaviours identifies the importance of drawing on a robust evidence base, that HIV interventions be directed at targeted groups, but the main thrust is ‘nudging’ people into healthier choices - a fine aspiration that can only be achieved by extensive awareness raising and by greater health promotion and education. Without national intervention this is a costly programme for local authorities.
There follows short but useful paragraphs highlighting the causes of poor sexual health that are not always recognised - involvement in prostitution, the experience of female genital mutilation, sexual exploitation or sexual assault, living with disabilities or homelessness.
Whilst the Framework will be a useful tool and ‘guide book’, a great deal is based on aspiration and the reliance of integration of different strands. Integration through the Health and Wellbeing Boards, integration of local government services that relate to the provision of good sexual health (although little is discussed of the patient, the clinical staff, the voluntary sector) and finally the integration and cross referencing with other government departments that influence relevant policy and practice.
My final point in reviewing the Framework relates to accountability - how will the various commissioning agents, local government, Public Health England be held accountable in determining whether they are providing sexual health services to meet the needs of the population? And lastly, there is the question of the accountability of the Government, which ultimately has the responsibility for ensuring that the stated ambitions within the Framework are met.
However, now that the Framework has been published, let’s not waste any more time. I hope those working at a local level will seize the moment and use the evidence, interventions and ambitions contained within the Framework to champion sexual health and ensure that the new system commissions and provides comprehensive and accessible services that meet the needs of local communities and ultimately improve sexual health outcomes across the population.
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