Sexual and Reproductive Healthcare

I would like the Minister to reflect on the effective dismantling of the Office for Health Improvement and Disparities. It took over the funding of the public health grant when Public Health England was disestablished in 2021, which in turn, of course, replaced the Health Protection Agency following the Health and Social Care Act 2012. It has now been authoritatively reported in the Health Service Journal that unannounced changes to the office have led to its fragmentation and decimation.

So over 12 years we have seen, through a number of iterations, the Government essentially move from having a large, mainly independent public health agency to a disparate group of people spread thinly across a number of directorates in the Department of Health. At what cost? I have seen reports that OHID has been reduced by about 60% in staffing terms, with a loss of several senior and experienced officials and the downgrading of many functions, including sexual health. Can the Minister tell me how many qualified public health specialists have left OHID and how many remain within his department? It is a far cry from the triumphal tone of the announcement launching the office, followed by the September 2021 statement by the then Health Secretary, Sajid Javid, who said he wanted OHID to work on preventing poor mental and physical health, addressing health inequalities and improving access to health services, and to work with partners within and outside government to respond to wider health determinants. That ended well, didn’t it?

My noble friend Lady Merron anticipated this in her regret Motion of 9 November 2021. As she put it, it is hard to see how the UK Health Security Agency or the OHID could be “independent or effective”. They were not set up in statute and were created

“without parliamentary scrutiny or approval”.—[Official Report, 9/11/21; col. 1675.]

As we can see, it is very easy then virtually to dismantle OHID without any public or parliamentary scrutiny whatever. Hunter, Littlejohns and Weale, in a forthcoming BMJ opinion column, will argue:

“Set up in haste with no consultation, OHID lacks any of the … independence PHE had, being an opaque body scattered through the Department of Health and Social Care. Given its low profile and lack of a clear mission, it comes as no surprise that, despite denials from the government, it has been virtually eviscerated”.

Or, as Dave West from the HSJ has put it,

“the latest restructure, as well as being damaging to a functioning national public health system, suggests any idea of greater push and support from the centre for independent for ICSs’ long-term agenda—of population health, prevention inequalities—remains for the birds. Hopes of tougher preventative action on alcohol or sugar, for example, equally so”.

That has to be on a par with the Government’s tepid approach to public health measures, smoking aside. The shamefully postponed implementation of the obesity strategy is but one example, and it is in this context, of course, that we see the problems arising in sexual health. How else can we explain the LGA’s analysis that, between 2015 and 2024, the public health grant received by local authorities has been reduced in real terms by £880 million, which has resulted in a reduction in councils’ ability to spend on STI testing, contraception and treatment? As David Hunter and his colleagues argue, revitalising public health in the UK requires changes, including a cross-government approach to tackle the social determinants of health alongside restoring the funding cuts to public health funding. Will the Minister effect that change, including restoring the real-terms value of the public health grant, the cut to which has so decimated sexual health services in the way described by the noble Baroness, Lady Barker?

“stillbirth, miscarriage, or neonatal death”.

If the baby survives, among the effects are

“blindness, deafness, developmental delay, or skeletal abnormalities”.

It is interesting that there is a parallel between what is happening here in the UK, with different structures, and what is happening in the US, because the US, as the CDCP says, has an acute failure in terms of neonatal syphilis—the number of babies born with neonatal syphilis in 2022 was 10 times greater than in 2012. The CDCP says that testing and treatment during pregnancy could have stopped 88% of those cases.

I reflect on those US figures because we are seeing increasingly an Americanisation of our healthcare system: a copy of the US healthcare system’s models; an import of US companies; and an import of people with professional experience, particularly managerial experience, of the US system. This is a system that the CDCP, citing the syphilis figures, says is a total failure. That is something we should really reflect on.

I should probably declare my position as a vice-president of the Local Government Association. I will pick up figures that have already been mentioned, but that have to be highlighted. Among the largest reductions in public health spend since 2015 has been spend on sexual health services—29%—yet at the same time, there has been a significant increase in demand for sexual health services: nearly 4.5 million consultations in 2022, up by a third in a decade.

Of course, we are always hearing elsewhere in your Lordships’ House about rising costs. Sexual health clinics and services are no more immune from the costs of rising energy prices and rising staff costs, et cetera, than anywhere else. The funding is falling and the demand is increasing, so of course the needs are not being met. I reflect back on the debate earlier this week on the Budget. Member after Member of your Lordships’ House got up and spoke about “broken Britain” and our broken services. The noble Baroness, Lady Vere, for the Government, said at the end: “Oh, I think you’re all being too gloomy”. Well, I am afraid that if we look at the state of our sexual health services, we see that the phrase “broken Britain” is sadly appropriate.

I acknowledge having drawn on the excellent briefings we have received, and I now turn to training. We have received demands, which seem perfectly fair and reasonable, that all sexual health medical training posts be 100% funded through the NHSE, in the same way that posts in primary care, oncology and public health are funded, and that the NHSE be accountable for ensuring that some of the recruitment gaps that the noble Lord, Lord Hunt, referred to are filled in. This is important and relates to some of the other debates we have had about the importance of expertise and of proper, full medical expertise being involved at all levels of the health service. No service should be allowed to operate without a genitourinary consultant, and meetings of organisations and commissioners must include them.

I come to two more specific asks. We have a contrast in asks from the briefings. The Terrence Higgins Trust calls for a high-level sexual health commission to address these issues, while the National AIDS Trust calls for a national sexual health strategy. I do not have a particularly strong position on which of those is the right way to approach the crisis, as all these organisations are saying, in different words, are the Government going to take serious, significant action? They may not have very long to go as a Government, but this really cannot wait until we have had an election—whenever that is.

I come back to an issue I have raised a number of times before in the House: the patchy provision of postal STI and HIV testing across England. Only during one special week, the national HIV testing week, can everyone access this testing from a single service. That makes England an outlier. Wales and Scotland already have national HIV postal testing services. In Wales, that also includes STIs, and the Scottish Government are also moving in that direction. It would surely be cost-efficient and cost-effective to make available to everyone in England a national HIV and STI testing service. It would be an extremely good way to spend government money.

I also want briefly to raise the issue of chlamydia testing. We had a full national chlamydia screening programme that included both young men and women, but that was cut back in 2021 from preventing chlamydia infection to reducing the harms of untreated chlamydia. As a result, chlamydia has come to be seen as a women’s issue. Of course, infection occurs in both sexes, but that is not being drawn to the attention young men in particular. Will the Government reverse that change and reinstate the full national chlamydia screening programme service?

The final thing I want to address is people living with HIV who are no longer engaged with services. The Government estimate that some 14,000 people have not been seen at their HIV clinic for at least a year. That is a real risk to the health of people living with HIV and a significant threat to the Government’s goal of ending new HIV cases by 2030. Of course, this issue relates to many other policy areas that the Minister cannot deal with, such as poverty and homelessness, but surely there should be within health a programme to re-engage people with HIV, who should be being cared for not only in their own interests but in the interests of the health of the nation and the whole of society.

In terms of the broader questions around the workforce, there are three structural questions that I really wanted to put to the Minister. First, can he, hand on heart, say that the Government are taking sexual health seriously when we see the kind of cuts that we have heard about to public health budgets? Those are compounded by crises in local government funding, so the bodies that we need to respond and provide the information—public health services and local government writ large—are seeing significant cuts. I hope the Minister can offer something. We have often brought funding crises to him, and pots of money have been found and dished out for various reasons, but I have not heard of one in this space. I hope that he will think about that. It is really hard to take the Government seriously on this issue when the people who have to deliver the service are seeing their budgets cut year on year.

My second question is one that the noble Lord, Lord Hunt, raises around the role of integrated care boards and integrated care services. I was interested to read the briefing from our friends in the Library, which says that the workforce plan tells us that:

“Workforce planning, development and training for public health areas such as sexual and reproductive health and alcohol and drug treatment should benefit from improved joint working between ICBs and local authorities”.

I emphasise “should”; I do not think that “should” is good enough. I would really like to hear the Minister give any examples the Government can point to that say they “are” benefiting from this ICB structure. I know it is early days; we have been talking about it being early days for about a year, but at some point we should see the benefits that the ICBs should deliver. This is one of those critical areas, where it is joined-up working and the pooling of resources between the two services—local authority-delivered services and traditional acute community and primary healthcare services—that will deliver the benefit.

The third question is on workforce planning—the really interesting question of how all the different pieces are working together, underneath the headline which the Government have talked about. We on all sides of the House have praised the fact that we have these headlines. Again, it is time to dig into some of that detail. There are really two key issues. One is to say how the different pieces fit together because, as the noble Lord, Lord Hunt, has pointed out, there have been experiences where a push to recruit in one bit of the health service has led to that bit of the health service that now has the money hiring people from some other part of the health service that then, a year later, finds itself in crisis. We really need to understand for all these services how these pieces are being meshed together. It is like a waterbed: you push down on one point and another point pops up. The pressure needs to be applied very thoughtfully. There needs to be a bigger bed, for a start, but once you have that, you need to be really thoughtful about how it works to push down in one place and push up in another. It would be helpful to hear more from the Minister about how specific services like these—where you can imagine the recruitment for one service could come from another form of nursing or public health—can be knitted together.

The second issue is thinking about how people behave in their careers; they behave quite rationally. My noble friend Lady Barker referred to the shortage of GUM specialists. As people go through their training and build their career, they will respond to signals about where the opportunities lie. If they see that the funding has been cut in a particular area and the jobs are not going to be there, they will make rational choices.

Again, we need to hear from the Minister—and perhaps also, in an election year, from the Opposition—what signals the Government can send out to make sure that somebody going through the early stages of their career, who is interested in delivering sexual and reproductive health services, will that feel it is worth doing the training because the jobs are going to be there at the end of it. They are going to make a rational choice; that is what we are seeing. Some of the suggestions that my noble friend made are precisely around the fact that we are not getting the specialists that we need in this area coming through because people are choosing to get trained in other specialties instead.

I hope the Minister will be able to respond on these key areas around workforce planning, as well as to the excellent suggestions made by my noble friend. Again, I thank her for giving us this opportunity to talk about an area that is critical, particularly—though not exclusively —for younger people. When mistakes are made at that stage and they do not get the help they need, they can end up with conditions that will affect them for the rest of their lives. We need to do all we can to prevent that from happening.

As this is the case, how can the Government assure themselves that they are satisfied with the impact of the funding that they provide? How can they address, therefore, the very real questions that have been put in the debate this evening?

I turn to the current state of demand. The Local Government Association, using data from the Office for Health Improvement and Disparities, reports on a number of areas. For example, almost all council areas have seen an increase in the diagnosis rate of gonorrhoea, with 10 local authorities seeing rates triple, while nearly three-quarters of areas have seen an increase in cases of syphilis and more than one-third of local authority areas have seen increases in detections of chlamydia. It is interesting to note that councils, as well as other groups, have called on the Government to publish a new 10-year sexual and reproductive health strategy to address infections in the long term. Perhaps the Minister could advise the House what consideration the Government have given to that proposal.

An analysis by the Guardian just last month found that spending by English councils on sexual health services had reduced by one-third since 2013 despite a rise in the necessity for consultations for sexually transmitted infections. Advice, prevention and promotion services have had the largest cuts to funding, with net spending down some 44% since councils were made responsible for public health in 2013. Meanwhile, STI testing and treatment fell by one-third and contraceptive spending by nearly one-third. Yet we know it is costly for people to end up in hospital who could otherwise have been treated through sexual health and reproductive services. So could the Minister comment on how cuts such as these make sense in terms of value for money, when research shows that each additional year of good health achieved in the population by public health interventions costs £3,800, around three times lower than the costs resulting from the NHS interventions that become necessary in the absence of those preventative measures?

The noble Baroness, Lady Barker, was right to draw attention to the workforce that is necessary to provide these services. There have been many warnings that a large number of skilled medical staff have left the NHS and, even in the unlikely event of a major injection of resources, it would just not be possible to replace that loss of workforce overnight.

I think we in this Chamber all agree that long-term workforce planning is essential to ensure the sustainability of crucial sexual health services. There is currently a retirement cliff edge for all members of multidisciplinary teams. That has been exacerbated by difficulties in recruiting new staff into the specialty, as well as the experience of the pandemic, which saw more healthcare professionals leaving the sector. As we have heard today, there is an urgent need to recruit new trainees by addressing the low number of training posts in GUM and HIV and lower awareness of the specialty. A survey of RCN members reported that sexual and reproductive health is not regarded as attractive to new staff, while concerns were also raised about the diminishing options for education and training. That is borne out by the limited exposure to the specialty that we see in undergraduate training and in the core general training following medical school—something highlighted by the noble Baroness, Lady Barker.

In all this, the failure to plan and invest in a sexual and reproductive workforce only exacerbates pressures elsewhere in the healthcare system. People are being pushed into hospital now due to untreated STIs, with admissions to hospital for syphilis and chlamydia doubling between 2013-14 and 2022-23 while gonorrhoea admissions have tripled.

As the noble Lord, Lord Allan, said, the workforce plan refers to what I would describe as a hope—a hope that there will be benefits from improved joint working between ICBs and local authorities on workforce planning, development and training for public health areas, including sexual and reproductive health services. In answer to a Written Question that I tabled last month, the Minister confirmed that NHS England conducted an annual performance assessment of the ICBs for the 2022-23 financial year. Can the Minister indicate what assessment has been made of those promised improvements through joint working in respect of sexual and reproductive health services; in other words, is the joint working delivering in the way that the workforce plan hoped for?

Importantly, how will the Government address the very real issues that have been highlighted in this debate? They are real, they have been with us for years and they need resolution.

The action taken by the Government—which was recently applauded during Elton John’s visit, as noble Lords will remember—includes standard things such as opt-out HIV testing in every circumstance where people are going into A&E. This has already detected 1,000 people with HIV who were previously undetected. That is absolutely ground-breaking in the world. We were also applauded for the action taken on HIV through PrEP. Call me old-fashioned, but I would rather look at the results we are achieving than at how much we are spending, and I hope noble Lords would join me in that. On the results, according to this independent source and against the UN HIV target, we undeniably come out very highly.

However, I do not want to appear complacent. Clearly, far fewer people are using condoms—often for very good reasons, because there is not the same fear of sexual disease and HIV. So there are societal changes, but that brings some challenges regarding sexually transmitted diseases—that is understood. We are trying to make our funds go as far as possible, not just in services today but in introducing contraception and those services to pharmacies. Pharmacy First is making this very accessible—we are already seeing good take-up, and we expect about 30% of people to get their contraception through Pharmacy First. That is a real example of how we are massively expanding access to the workforce.

The long-term workforce plan is absolutely a bigger bed strategy, and I take the point of the noble Lord, Lord Allan, that we clearly need to make sure that that provides the individual specialisms that are needed. The Government and I accept that work will need to be done to make sure that those specialisms result from that. But I think all noble Lords will agree that the bigger bed strategy is right, and improvements will come through across the board.

The noble Lord, Lord Hunt, referred to Sexwise. The steps we are trying to take are sensible, and the Government did this well when they consolidated a lot of their different websites into a single source. We want the primary source of information we are pointing people towards to be the NHS websites, and particularly the NHS app, which I think all noble Lords would agree is completely appropriate for younger people. At the same time, I absolutely take the sensible point the noble Lord made about a group being willing take over Sexwise. Funnily enough, I said exactly that: “Why can’t we give it a contract for £1 if it is difficult to give it away? Why can’t we do something pragmatic along those lines?” That is the challenge I have set: if it is a good service and someone is willing to do that, why would we not want to support that? But I hope noble Lords see that, in general, it is a sensible strategy in the digital age to consolidate your assets around the overall NHS umbrella and the NHS app.

In response to the noble Baroness, Lady Barker, we definitely want to build on the women’s health hubs. STI and HIV screenings are part of their specifications. In response to the noble Baroness, Lady Bennett, we have hepatitis B, HIV and syphilis as standard parts of the screening of pregnant women. That is seen as very important. I also absolutely agree about the importance of home testing in all this. As noble Lords will see, we are trying to use the NHS app as a vehicle for people to get home testing as they require.

The noble Baroness, Lady Bennett, asked about the advice behind focusing chlamydia screening on women rather than men. That is based on the scientific advice and evidence we have received that that is the best use of resources in this case.

I will write to the noble Lord, Lord Allan, on his very reasonable question about where young people get their information from in a letter detailing what we know. I accept that, if we do not have that information, we should find it out. Hopefully, we can come back on that. Likewise, I will need to come back further on what evidence we have to date on ICBs and the benefits of joint working. As ever, I will follow up on the detail in writing.

I am grateful for the opportunity for us to debate these things. This is one of those occasions where I can stand here in all honesty and say that, objectively, by a number of measures—looking at the results coming in, not at the funding—including from none other than the European Parliamentary Forum for Sexual & Reproductive Rights, Britain comes out at No. 1. That is something that we can all feel proud of.

There has also been a resurgence in neonatal syphilis in the UK—something that we thought was history is now back. We have significant neonatal morbidity. In addition, reduced NHS service capacity has reduced the access to preventive SRH services, including vaccinations and the provision of HIV PrEP, both of which are critical to reducing future transmissions of STIs. In some areas of the UK, particularly outside London, there has been a disproportionate effect, as small clinics have been hit more than others.

It is important to understand in this debate that there are two types of specialists who deliver the majority of SRH and out-patient HIV care in the UK: first, GUM clinics, and HIV physicians who are trained in medicine and specialise in STI and HIV diagnosis and management; and, secondly, community sexual and reproductive health specialists, who train predominantly in women’s healthcare and who specialise in the gynaecological and reproductive care of women across their life course. Most provision of specialist contraception and training of other healthcare workers in contraception, and the leadership of systems across secondary and primary care, is done by community SRH consultants.

Dame Lesley Regan has done tremendous work in the development of the women’s hubs. I ask the Minister whether the Government plan to build on that work to make those into one-stop shops for women, where they can have their reproductive and sexual health issues dealt with all at once.

HIV treatment is different—HIV services are open-access and anybody can come into them—but there is a huge problem in the HIV workforce. Not only is there huge demand; there are so few consultant specialists around to help other staff to train and develop that we are now having a real problem recruiting trainees into genitourinary medicine. That means that those services are becoming ever more fractured, and there is a knock- on effect back to general practice and to pharmacies, which simply do not have the specialist knowledge and training to deal with those more complex cases.

Nurses and allied healthcare professionals are doing much more than they did a year ago, but they cannot deal with the sorts of complex cases that are now being presented to them. We have an inadequate number of consultant specialists working in the field and that is having an adverse effect on training.

Commissioning arrangements are at the root of the problem in all of this. No one is taking responsibility for ensuring that the next generation of doctors and nurses in sexual health services are being trained. No local authority has a training plan and there is no cohesion nationally to drive accountability where it fails. Services that offer no training and education are inherently cheaper and those are the ones being commissioned more and more—for short-term gain for cash-strapped councils, but with long-term harm to public health.

I ask the Minister to address three critical issues: first, making sure that all sexual health medical training posts are 100% funded through NHS England in the same way that posts in primary care oncology and public healthcare are funded; secondly, that NHS England is accountable on its plan to ensure improved recruitment, with the publication of a corresponding action plan to deliver improved recruitment in sex and reproductive health; and, thirdly, that no service is allowed to operate without a GUM consultant within it, no matter how much it depends on lesser-qualified staff.

It is worrying that we are going back to levels of sexually transmitted diseases that we thought were a thing of the past. It is deeply frustrating, because we now have the medicines to deal with these cases, and we know there are new technologies and ways of delivering services that could make the system so much more efficient. If we had nationwide home testing kits for HIV, if we had a greater use of pharmacies for the management of people with HIV in their local areas, rather than them having to go to specialist clinics for ongoing treatment, we could be making great progress. In this field, as in many other parts of medicine, were staff to have the time to sit and think through the ethics and potential of the use of AI, we could make huge strides forward in these public health matters. As it is, these services are stretched to breaking point.

I want the Minister to answer two simple questions. First, what are the Government going to do to stop the crisis and the downward spiral of stretched services relying on staff who are not sufficiently well trained? Secondly, what have the Government made of the lessons that can be learned from the GP recruitment crisis and the opportunities to apply those to increasing recruitment and retention in urinary medicine and HIV, including fully funding training posts? We need to get this workforce back up to the levels we know we can manage in order to deal with a crisis which need not have occurred in the first place.