Just two weeks before local authorities take over the commissioning of sexual health services – and twelve years since a sexual health strategy was last published – the Department of Health has released a “framework” which outlines the government’s ambitions for the improvement of sexual health in England.
Reaction has not been entirely positive. “The framework pays far too little attention to HIV at a time when infection rates are high, late diagnosis is common, and almost a quarter of people with HIV in the UK are unaware of their infection,” said Professor Jane Anderson, chair of the British HIV Association (BHIVA).
Dr Audrey Simpson of the FPA said that the document lacked "teeth" and that there was no guarantee that local councils would act on it. “While there is much in this framework to take heart from, unfortunately the government’s rhetoric for improving the entire nation’s sexual health does not match up to the reality on the ground,” she said.
Responsibility for planning and purchasing local sexual health services moves, at the beginning of April, from the NHS to local authorities (i.e. local councils and boroughs). Sexual health clinics, testing projects, contraceptive services, teenage pregnancy initiatives and HIV prevention projects will soon become the responsibility of local authorities, working under the supervision of elected local councillors. With budgets under pressure, there is likely to be considerable upheaval and disruption in the coming years.
The Department of Health says that its framework has been published “to set out for commissioners and providers the government’s ambitions for good sexual health and to provide information about what is needed to deliver good sexual health services”.
But as government policy is for decisions to be made at a local level, the framework does not describe any new programmes, policies or targets. Instead, it provides a brief overview of some of the issues which sexual health services need to address, without giving many clear recommendations for action.
Most organisations that have publicly responded to the framework have acknowledged that it draws attention to important concerns. Terrence Higgins Trust said that it treats sexual health as a public health priority, National AIDS Trust noted that HIV testing and prevention are given the emphasis they deserve, and Brook commended the document’s ambition that all young people should have access to confidential services and support.
Moreover, the document acknowledges the role that effective HIV treatment can have in reducing onward transmission, draws attention to HIV testing in non-specialist settings, discusses primary HIV infection, briefly mentions pre-exposure prophylaxis (PrEP), highlights the sexual health needs of people over the age of 50, and considers the impact of drug and alcohol use on sexual health.
HIV prevention is clearly identified as needing to be targeted towards the groups who are most at risk of infection – men who have sex with men and African communities. The government’s ambition is that individuals understand what HIV is, how to reduce the risk of transmission, how to prevent HIV and where to get prompt access to confidential HIV testing. People diagnosed with HIV should receive prompt referral into care, high-quality care services should be maintained, and people with HIV should receive early diagnosis and treatment of STIs.
The framework states that different commissioning bodies should work together to ensure that close links are made between services offering testing, prevention and treatment. More generally, in several places the document says that different commissioners (local authorities, the NHS National Commissioning Board and clinical commissioning groups) should collaborate so that services are not fragmented.
But whereas local authorities will be required to commission comprehensive, open-access clinical services for sexually transmitted infections and for contraception, the document draws less attention to local HIV prevention and sexual health promotion activities. When they are provided, local authorities will be the commissioners, but the framework does not establish an expectation that all local authorities should commission such services.
And although HIV prevention and testing should be targeted to gay and bisexual men, the particular needs of this group are somewhat understated in the framework. Most notably, in the section on sex and relationship education (SRE) for the under-16s, there is no mention of SRE having to meet the needs of young people who are not heterosexual.
Moreover, while Simon Blake of Brook said that he was “pleased to see the ambition that all children and young people should receive good quality sex and relationships education at school”, he was sceptical about implementation. “This ambition will never be realised whilst the Department for Education fails to ensure that every school is required to deliver a comprehensive programme of SRE.”
Deborah Jack of the National AIDS Trust also pointed out that this is not a comprehensive HIV strategy that addresses the full range of issues associated with HIV. “Treating HIV as merely a STI is not the whole picture,” she said. “HIV is not simply a health issue and the responsibility of the Department of Health. The Department for Education, the Department for Work and Pensions, the Ministry of Justice, the Home Office and Department for Communities and Local Government to name a few, all need to consider how their policies affect people living with HIV.”
Department of Health A Framework for Sexual Health Improvement in England, 2013.
Department of Health. Commissioning Sexual Health services and interventions: Best practice guidance for local authorities, 2013.