Summary

• A cross-governmental approach is needed to tackle the broader social and economic determinants of sexual ill-health which are not properly addressed in this strategy.
  
  
• Sexual health in England is deteriorating and services increasingly lack the capacity to cope. The strategy provides a great opportunity to reverse these trends, but it will not be effective without long-term commitment to a much bigger investment of resources.
  
  
• Service standards are essential and must be developed for all levels of service provision, including settings outside the mainstream such as prisons.
  
  
• Greater involvement of primary care in sexual health is needed, but will require training and more GP and staff time, implying a significant increase in financial investment in this setting.
  
  
• Resources are also needed to increase access to GUM services, especially by the most vulnerable groups, and for the related laboratory and diagnostic services.
  
  
• Clear guidelines and support are needed for the wider range of health professionals who will be expected to offer HIV testing, especially those in primary care.
  
  
• Specialist health promotion services must be maintained despite the NHS structural changes, in order to support health care professionals and to implement community based interventions with populations most at risk.
  
  
• Further clarification is needed, especially in the context of organisational change in the NHS, about the implementation of HIV service networks, HIV commissioning, and the application of the strategy’s targets.
  
  
• Specific attention is needed to ensure the actual, and perceived, confidentiality of sexual health services in primary care. In particular, action is needed to overcome the barrier posed by the requirement for GP reports for insurance.
  
  
• A more open social climate in relation to sex and sexual health must be fostered at all levels of society, from statements by government ministers to evidence-based sex and relationships education for all young people.
  

Scope of the strategy and our response

Like many other organisations in the HIV sector, we share the government’s view that there is a relationship between sexual ill health, poverty and social exclusion, and that inequalities in health must be addressed. We believe that tackling such inequalities requires cross-governmental action to address the broader determinants of sexual ill health. This strategy concentrates almost exclusively on the NHS and primarily medical solutions, and in our view this is too narrow.

However, there is still much to comment on within the scope of the strategy as it stands, and as the BMA Foundation for AIDS’ expertise is largely in the health care domain, this will be the main focus of the response which follows.

Resources and implementation

We welcome the National Strategy for Sexual Health and HIV, which is badly needed. With no strategy in place until now in this area of health (except on teenage pregnancy), planning has been dominated by uncertainty, inconsistency and short-termism. If this continues, it is hard to see how the increases in rates of HIV and other STIs will do anything other than continue. Professionals in most sectors are struggling with increased workload and there is the risk of decreasing motivation. The strategy offers an opportunity to put in place and implement a coordinated and geared-up national response to the increasing burden of sexual ill-health. It should be seen as a tool for galvanising, re-motivating and resourcing all services dealing with sexual health.

But it is important to stress that the strategy can only be effective if it is supported with adequate resources, financial and human, for its implementation. The allocated sum of £47.5m over the first two years is inadequate given the scale of the task, and a commitment to continuing resources over the ten years of the strategy is also needed. The need for resources is a thread which runs through this whole response.

Mechanisms must also be put in place to encourage, enable, and where necessary enforce, the strategy’s implementation. We applaud the stated intention to develop a detailed programme of action. This should be monitored and reviewed over the life of the strategy.

Service levels

The three levels of service provision offer a flexible way of improving the consistency, quality and connectedness of sexual health services. We also welcome the move towards greater horizontal integration of different aspects of sexual health care, taking a patient-centred approach. We strongly support the strategy’s emphasis on the development of standards and believe these must be developed for all levels of service provision.

It is important that services provided in other contexts, such as prisons or detention centres, offer equivalent standards of care. These need to take account of the particular circumstances, such as how to ensure continuity of treatment when prisoners are transferred or released. In relation to highly active antiretroviral therapy for HIV, the recognised risks of sub-optimal adherence to demanding treatment regimens make this more important than ever.

Capacity in primary care

There will be a need for adequate numbers and training of willing GPs and other members of the primary care team, both to ensure consistent quality of 'level 1' care and adequate numbers providing 'level 2'. In primary care, where a greater involvement in sexual health will be expected as a result of the strategy, standards should provide a framework for education and training, as well as a tool for commissioning services of consistent quality and monitoring their delivery.

The already increasing annual diagnoses of STIs, combined with the strategy’s drive to raise awareness and encourage testing, mean there is bound to be an increase in workload. Resources will be needed for more GP and staff time in the primary care team.

Treatment for STIs is currently free in GUM services. If treatment is to be routinely provided at level 1 and 2 in primary care in an equitable way, this should also be free of charge.

Capacity in GUM

Additional resources are desperately needed for GUM services, where recent research has indicated that the current limited access due to overdemand on existing services is likely to result in increasing morbidity (Foley, E et al. Access to genitourinary medicine clinics in the UK. Sexually Transmitted Infections 77:12-14 (2001)). To encourage use of GUM services it is essential to maintain the principle of open access. To increase uptake of GU services by hard to reach, vulnerable population groups, there will be a need for more investment in outreach work and use of less invasive but more expensive diagnostic tests - these require resources.

Networking between primary care and GUM

Increased networking across the service levels, between GUM and primary care, should improve the quality of sexual health services and reduce attrition rates during patient referral. This networking might, for example, include health advisers working with primary care on partner notification, smoother access to laboratory testing for a range of infections, and staff training, secondments or shared posts. However, given the level of demand currently experienced within both primary care and GUM, it cannot be expected that closer working will be sufficient to ease the backlog and ensure adequate speed of patient access without the investment of significant additional resources to increase capacity.

HIV testing

The drive to reduce rates of undiagnosed HIV infection is important. Making testing more routine in GUM, and available in a wider variety of settings, must be the right approach. There are already examples of good practice, but some non-HIV specialists, especially in primary care teams, will need resourcing to develop the skills and confidence to offer testing and deal appropriately with both positive and negative results. This will include the provision of a culturally appropriate environment for population groups most affected by HIV as well as services such as interpreting or advocacy when needed. Efforts and resources will be needed to ensure socially disadvantaged and marginalised groups do not have difficulty with access eg through hard-to-negotiate appointment systems.

The Department has, in the past, provided advice on pre-test "discussion". However, the list of level 1 services in this strategy refers to HIV testing and "counselling". In the context of increasing uptake and normalising HIV testing, this would appear to be a step backwards. It will be important to give clear guidelines on what the offer of HIV testing should involve, taking account of different settings, different reasons for testing, and different population groups. Clear protocols are also needed for dealing with results, especially those which are positive.

Laboratory and diagnostic services

Increased levels of testing for HIV and a range of other STIs, including through the chlamydia screening programme, will increase the demand on laboratory services. Less invasive but more expensive tests will also drive up costs. Bigger budgets will be needed.

In HIV, the growing complexity of tests to support treatment decisions, such as those for viral resistance, requires the allocation of resources not only for laboratory work but also for the provision of expert advice to clinicians on the interpretation of results.

Health promotion

There is a compelling rationale for continued investment in health promotion. There is scope for both planned and opportunistic health promotion interventions by health care professionals, but such interventions need time and hence additional resources.

Resources are also needed to maintain specialist health promotion services, which can provide training and advice to health professionals, including primary care staff, and information materials for patients. These services also have an important role providing health promotion in the community, including work to target the most vulnerable population groups, the nature of which often requires them to work across PCT boundaries. The existence of such specialist sexual health promotion is threatened by the NHS changes outlined in Shifting the Balance of Power in the NHS and by the removal of the ring-fence on HIV prevention funding. It will be important for the Department to ensure that mechanisms are in place to ensure the continued existence of such services, for example through guidance to PCTs on commissioning and to Strategic Health Authorities on the functioning of public health networks and performance management.

Service networks for HIV treatment and care

Having focused much of our own recent work on facilitating the development of HIV service networks, as referred to in the strategy, we are very pleased with the unequivocal statement that all HIV treatment and care should be given within managed service networks. We support the strategy’s more detailed recommendations on this. It is also very helpful that broader government health policy supports the development of networks. However, there are different models of network and conflicting understandings may hinder delivery.

Shifting the Balance of Power in the NHS describes "clinical networks" fostered by NHS Trusts, supported in their development and performance-managed by Strategic Health Authorities, and with clinicians in control. The strategy describes "managed service networks", whose development will be led by commissioners and whose membership is broad and multi-disciplinary, extending into primary care and beyond the NHS. We believe the latter model is appropriate for HIV and based on elements of existing good practice in the sector, but more needs to be done to clarify expectations and requirements:

• Which commissioners will lead the development of HIV service networks?
• Will networks themselves be commissioned?
• Will they be managed and by whom?
• Who will ensure that "all HIV practitioners… work within a managed service network"?
• And how is patient involvement to be ensured in the development, running and monitoring of networks?

In our project experience, it is important for networks themselves to be resourced, for example to pay for cover for clinicians to attend network meetings and educational events, to provide improved electronic communication, and to pay for time to manage and coordinate the network.

HIV commissioning

It has been recognised that HIV treatment and care is "specialised". Clarification of arrangements for specialised commissioning are needed. At what level will this take place, following implementation of Shifting the Balance of Power in the NHS? How will it relate to the local sexual health and HIV plans to be developed by local multi-agency commissioning groups? Will commissioning take place purely through individual providers (eg NHS Trusts) or will there be commissioning of HIV service networks?

Firm mechanisms are needed to ensure adequate resources are invested by local commissioners in HIV prevention, following the removal of the ring-fenced funding allocations for HIV prevention. Particularly important, but easiest to abandon, are prevention activities with the marginalised groups (gay men, African communities, injecting drug users) who are most at risk. Without such interventions, the strategy’s challenging targets will not be met.

Targets

Setting challenging targets, as the strategy does, is a helpful way of moving sexual health and HIV up the already over-cluttered list of health service priorities. But for the targets to drive commissioning and service provision at a local level, further clarification is needed. Will they apply at local, or only national, level? How will progress towards them be monitored? Will there be rewards for success and sanctions for failure (like the traffic light system)?

Confidentiality

In the sensitive area of sexual health and HIV confidentiality is crucial, and a sophisticated understanding of this must be fostered in all staff involved, from clinicians to receptionists. The specific regulations affecting GUM and the experience of these services in dealing with confidentiality tend to inspire greater confidence in service users. This confidence must be gained by primary care if fears about lack of confidentiality are not to serve as an obstacle to the provision of sexual health services in this setting.

In particular, the requirement for GPs to provide reports to insurance companies when patients are applying for life or health insurance acts as a disincentive for the doctor to ask for, and the patient to share, information about his or her sexual health. Recent GMC guidance has emphasised the need for fully informed patient consent but this does not address the well-informed patient’s (or GP’s) reasons for seeking (or advocating) provision of sexual health care elsewhere. Alternative means of providing medical information to support insurance applications should be available which do not threaten the GP-patient relationship.

The social climate and attitudes to sex

Evidence from other countries in Europe shows the health benefits of a more open attitude to sex and sexuality, a greater willingness to discuss sexual matters and to use sexual health services without stigma. The government promised in 1999 that its sexual health strategy would aim for a "more mature attitude to sex". The strategy does little to address this explicitly, but a lead from government is needed to combat the stigma associated with sexual health and HIV. The provision of sex and relationships education for young people based on evidence of effectiveness is a crucial base on which to build a more sexually healthy society.