Debate on the Address

My Lords, I will be concentrating my remarks on the commitment in the gracious Speech which reads: "““My Government will carry through the modernisation of healthcare based on the founding principles of the National Health Service””." As chair of the Independent Advisory Group on Sexual Health and HIV, I, like the noble Lord, Lord Fowler, will take this rare opportunity to talk about sexual health. But I shall focus on the effects of modernisation and restructuring on the provision of sexual health services in this country. Over the past five years there has been a devolvement of services to SHAs and PCTs, along with guidance which will revolutionise the way services are commissioned and provided. The guidance includes the introduction of practice-based commissioning, which moves commissioning to the local level, in many cases to that of the GP; payment by results, which allows for the acute sector to be paid on a case basis for its work; the introduction of the choice agenda to give patients and service users a voice; and Our Health, Our Care, Our Say, which outlines a new direction for community services. This modernisation agenda is occurring against the backdrop of extensive boundary changes for SHAs and PCTs, making the latter in the main coterminous with local authority boundaries, thus allowing planning for local populations on a larger scale to become viable. But the generic nature of these changes does not take into account the provision of sexual health services in community settings. Having said that, I must add that where there has been investment in leadership, planning and innovation at the local level, sexual health gains can be made and money saved, but such investment is not universal with the level of provision being very different from one PCT to another. Sexual health provision has for far too long been underfunded, under-prioritised and effectively ignored. It was therefore seen as a huge step forward when the first ever strategy on sexual health was introduced in 2001, while in 2004 the Choosing Health White Paper set out clear plans and targets to improve sexual health services and committed £250 million for front line provision to achieve these ambitious plans between 2005 and 2008. This was followed by the rollout of the chlamydia screening programme and 48-hour access to GUM services being identified as an NHS health priority. It has to be said that high quality sexual health services provide a virtuous circle of health improvement which is a model of preventive healthcare—chlamydia screening as a means of reducing future infertility, comprehensive contraceptive services as a means of preventing unplanned pregnancy, and so on. All these preventive measures are significantly cost-saving in the long term. However, in the short term financial difficulties across the NHS have had a direct impact on sexual health services. Despite the prioritisation and investment in Choosing Health, it seems that sexual health has been seen as a soft target for cuts by primary care trusts. As the noble Lord, Lord Fowler, indicated, the review by the independent advisory group revealed that almost two-thirds of the PCTs surveyed withheld some or all of their Choosing Health allocation for sexual health primarily to address their financial deficits, resulting in staff cuts and clinic closures. In London alone it is estimated that less than 5 per cent of the promised budget is reaching front line services. The possible reason for this is that none of the allocation was ring-fenced. All this information has of course been passed to the Secretary of State. One cannot believe that disinvestment in sexual health services is occurring because PCTs do not understand the nature of the threat posed by poor sexual health. Therefore we must conclude that in the face of a number of pressing priorities, sexual health has been relegated yet again to a position of no importance. We have a long way to go before the epidemic of sexually transmitted infections is successfully tackled, before we can be satisfied with the level of contraceptive services, and before we can be sure that we are meeting the needs of patients—patients who have a very quiet voice. They are not going to sign petitions, lobby, organise or go on demonstrations. All this is taking place when we see a deteriorating level of sexual health in the UK, with increases in bacterial and viral sexually transmitted infections, including HIV. I do not apologise for repeating the figures given earlier by the noble Lord, Lord Fowler. STI data published in 2005 by the Health Protection Agency show that while there has been a decrease in gonorrhoea of 13 per cent—a positive effect of being included in local development plans—there has also been a 12-fold rise in cases of infectious syphilis, up by 23 per cent and now at its highest level since the 1950s. There has also been a 5 per cent increase in chlamydia, with one in 10 people under the age of 25 being infected. The incidence of HIV is rising, with over 7,000 new diagnoses in 2005. The next set of STI data will be published tomorrow by the Health Protection Agency, and we can only hope that we see some improvement in the figures. There is no room for complacency, but a greater need for concentration on innovation, on the development of networks and on the redefining of roles. We need a blurring of the delineation of the functions between doctors, nurses and health support workers, as discussed at the modernisation seminar commissioned by my honourable friend Caroline Flint, the Minister for Public Health. We also have to look at the local government White Paper and the co-ordination between PCTs and local government to provide healthy communities. A further effect is that many sexual health leads in SHAs and PCTs have lost their jobs or had them changed into a more generic function, with the loss of their knowledge and skills. Decisions around sexual health should be based on patient need and not on financial criteria. We must ensure that commissioning of sexual health services will not be compromised in areas where there is no strong lead in place, either managerial or clinical. It seems logical to me that services which require infection control and screening need to be viewed at a national level. A proactive approach must be taken to contain infection. The recently announced campaign to encourage condom use—““Condom Essential Wear””—is of course welcome, but that campaign answers only part of the problem. For example, it is pointless for one PCT to screen and treat chlamydia if the population six miles away—in the town centre, where all the popular night clubs are located and where the campaign will be directed—are not being screened and tested. This undermines all the benefits of a national screening programme. The current investment in screening will be pointless unless all PCTs fund screening for the target population. The inclusion of the 48-hour GUM access target in the top six NHS priorities has been helpful in keeping a focus on services, although, as I have indicated, many services are stretched in meeting that target. But when the target was announced my understanding is that it was part of the redesign of sexual health services as a whole. That may ultimately be the case but in the mean time services that cannot be replaced are being lost, particularly as there is no target for contraceptive services which are likely to be an easy target for disinvestment. There is an unclear national picture of exactly what contraceptive services exist, but we are hearing a disturbing amount of evidence of community contraceptive services under threat of closure, or closing. Failure to invest in contraception and services appropriate for community needs, especially those of marginalised community groups, will prove expensive on a national and personal level, leading to increases in abortions, and have a negative impact on teenage pregnancy targets. Good quality contraceptive services have been proven cost effective and an excellent early and on-going way to empower and inform women. Good contraceptive providers often build long-term relationships with women and can identify and deter risky sexual behaviours. Contraceptive clinics are also ideal for the early detection of STIs and other medical gynaecological issues, all of which are cost saving. In 2005-06, there were 2.6 million visits to contraceptive services made by 1.2 million women but, should community contraceptive services not survive the cuts, where will those women go? Not all GPs provide the range of services that are available and so many women will be deprived of personal choice. I quote one woman’s view from a survey carried out on possible cuts to clinic services. She said: "““Please do not leave us to rely on our GPs—it is very difficult to get an appointment or any advice beyond putting you on the pill””." I think that absolutely sums up the need to keep the contraceptive clinic services. But there is a further consequence: important training of future contraceptive professionals will be lost. Training needs to be captured within the commissioning framework to counter the current significant drop in training in all aspects of sexual health as PCTs decide they cannot afford the expense of releasing staff for training. Promoting the new sexual health campaign last weekend, the Public Health Minister, Caroline Flint, stated that the nation’s sexual health is a key priority. But she went on to indicate that there would be no additional funding despite the increase in sexually transmitted disease; that guidance on best practice and locally redesigned services were the way forward. She is clearly right—we have to look forward—but as we witness the NHS undergo profound and extraordinary changes, surely we want the modernisation of sexual health services to rise like a phoenix from the old order, rather than be lost in the birthing process. The consequences of SHAs and PCTs—and our health system and the Government collectively—not putting enough emphasis on tackling the current growth rates of STIs and HIV make it possible for the figures to rise to epidemic proportions. That must be prevented. Again I refer to the growth of syphilis, a disease we considered eradicated but which is now back with us. The moment is right to make very positive changes but I fear that if we blink and fail to address the reality of what is happening on the ground, we will miss it.