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Sexual Health: Contraceptive Services

Volume 691: debated on Friday 20 April 2007

rose to ask Her Majesty’s Government what steps they are taking to increase provision of contraceptive services, prevent the closure of specialist community clinics and increase the availability of training in contraceptive services and sexual health.

The noble Baroness said: My Lords, it gives me great pleasure to bring this matter to the attention of the House. I know that noble Lords—members of the all-party pro-choice and sexual health group—who cannot be here due to short notice, will read with great interest what the Minister says in response to the debate.

For 30 years of my medical career I was closely involved with family planning services and services for women in general, from the early years when services were run by charities such as the Family Planning Association, Marie Stopes and Brook, through to the heady years when services were at last taken over by the National Health Service and were free to all women who needed them—family planning and abortion counselling in particular. Those were very heady days for those of us who had campaigned so hard and long.

Special clinics were set aside for young people in every area. Screening services for cervical and breast cancer were introduced and latterly the clinics played a significant part in helping to meet the genito-urinary medicine 48-hour access targets. As noble Lords know, those clinics are very hard pressed and the community family planning clinics have helped a lot in that area. In most areas, initially area health authorities and then primary care trusts had a senior doctor and senior nurse to run the service. I was one such for many years, being head of women’s services for Ealing Health Authority. These community specialists managed the service, supported primary care and managed complex contraceptive problems in liaison with GPs if the latter did not feel competent to deal with them.

A faculty of family planning and reproductive health was formed at the Royal College of Obstetricians and Gynaecologists—a great leap forward—to set standards and organise training for doctors and nurses who wished to pass the faculty’s diploma or membership examinations. It was a very thorough and rigorous training with heavy emphasis on practical skills and took place under the guidance of a training doctor such as myself in the community clinics. Until recently, 80 per cent of the training of doctors in family planning took place in the community clinics.

In the early days women and young people loved us because the service was mainly walk-in and easy access, often to a woman doctor. We forget that 20 years ago or more there were not so many women doctors but patients liked to see one if they could, to avoid the embarrassment of seeing the family doctor, who they probably knew well, for very personal matters. The services were particularly valuable in areas with large ethnic minorities. I have worked among ethnic minority communities in Birmingham, north London and Southall, trying to make the services more accessible and to understand their problems in the context of their cultures. We even set up a cervical screening service in a local mosque for women who were either reluctant or prevented by their families from coming to a clinic. We provided the service in the mosque instead. The home visiting service was also useful for difficult cases.

When I entered Parliament in 1997 I received huge support and enthusiasm from the then Ministers, in particular Frank Dobson and Yvette Cooper, and civil servants at the Department of Health, particularly for my campaign to allow emergency contraception, the morning after pill, to be available over the counter in local pharmacies. That was another great leap forward for womankind. The Government are still hugely enthusiastic and supportive whenever we talk to them.

Both White Papers, The Health of the Nation and Choosing Health, have focused on public health and preventive health services, and the latest paper also promised an audit of contraceptive services. Three years later, however, we have still not seen the results. I am a little worried, because there may be nothing left to audit if it is not done pretty quickly. The audit is important because, despite £300 million being earmarked for sexual health services, there have been reports of closures of community family planning and sexual health clinics all over the country. We suspect that primary care trusts have used the money to offset their deficits and to address target services, such as the genito-urinary medicine clinic targets. Because there are no targets for the family planning service, it is a soft option for closure by PCTs, who expect the work to be done by the general practitioner.

Community specialist posts in reproductive healthcare, such as the one that I occupied many years ago, are not being advertised, and retiring doctors and nurses are not being replaced. Dr Penny Oakeley, whom I know and who is a hugely experienced and valuable doctor who ran superb services in Wandsworth, retired in September 2006, but the trust is not replacing her or the senior nurse, who retires this May. There is no intention of continuing the service. Doctors wishing to obtain the family planning diploma or membership now have great difficulty accessing practical training. They do not know where to go. That practical training is required under the NICE guidelines if they are to offer the full range of family planning methods, particularly the long-acting ones such as implants and IUCDs. We are telling patients that these methods should be available, but the doctors cannot access the training. The service is disappearing, and with it patient choice.

The Faculty of Family Planning and Reproductive Health Care conducted a survey of just under 3,000 clinicians in 2004, which is sadly a bit of a time ago. It was useful, however, and included GPs, family planning doctors, senior doctors in the health service, and consultant obstetricians and gynaecologists. Eighty-four per cent of GPs in that service were worried about the standstill or actual reduction in resources for family planning in their area. Ninety per cent wanted the services to continue to ensure that patients had choice and that there was the expertise for them to refer their patients to. Forty-five per cent were very concerned about restricted access to training in long-acting methods of family planning. Seventy-six per cent were concerned about the postcode lottery for abortion services, which I know the Minister will tell us has improved considerably, and it has. There has been a great improvement in abortion services, but I do hope that this improvement will be maintained, especially in the light of the news this week of the shortage of doctors willing to perform the operation. I suspect that there is another problem of a slightly different kind looming there. Eighty per cent of doctors surveyed emphasised the value of those community clinics for the distribution of condoms. Condoms are still seen as the first defence against sexually transmitted disease. Indeed, the fact that young people in particular can get them free in those clinics means that there is a way of contacting that young person and perhaps giving them more advice or letting them find out a little more about themselves and relationships and what they should do with their lives. Clinics are a very good point of access for young people in particular to get those free condoms.

To sum up, the faculty survey showed clear evidence of the lack of investment in family planning services. We are losing clinics all over the country, clients are being turned away from those that remain, and patients’ choice of method of treatment is being restricted. In the past three generations, there is no doubt that women’s lives have been transformed by the availability of contraception. The ability to limit the size of our families is a huge advance for mankind economically and socially, as well as environmentally, both in the developing world and here at home. Women are as vital now to the economy as they are to their families. This depends on them being able to limit the size of their families. I am not accusing the Government for one moment of neglecting this issue. In fact, I think they have spent a lot of time thinking about it, discussing it, agonising over it and surveying it. However, I very much want them to know this morning what is really happening out there. As a manager in the health service, I learnt quite often that you set your great plans and think that this is the way forward, but something quite different is happening on the ground, and you must be aware of the consequences of the action that you take. I therefore urge the Government to take my remarks seriously and to act. If they do not, women could lose so much.

My Lords, of all the many aspects of the Government’s truly woeful record on public health during their time in office, there is surely no failure more stark or more far-reaching than their failure on sexual health services. Noble Lords of all parties respect and admire the noble Baroness, Lady Royall, but it is rather telling that the Minister of State in the Department of Health, who has only just answered a debate in this Chamber, should have left the noble Baroness to reply to this one. I am, frankly, surprised at him.

These are major issues. My noble friend Lord Fowler, who has done so much to champion the promotion of sexual health services both as a Minister and ever since, has said that he regrets not being able to be here to take part in this debate. We are looking at a dreadful picture. England and Wales have the highest teenage birth rate in western Europe. In 2006, the Health Protection Agency recorded another rise in the incidence of most sexually transmitted diseases, notably chlamydia, where the graph has been moving upwards for the last 10 years. A few days ago, the Aids Funders’ Forum published stinging criticism of the services available for people with HIV/AIDS. Glenys Kinnock and the noble Lord, Lord Smith of Finsbury, who are both staunch friends of the Government, have added their voices to that criticism—Lady Kinnock stating that HIV is,

“one of the lowest priorities in the already neglected area of sexual health”,

and the noble Lord, Lord Smith, observing that,

“there are too many people living with HIV who are simply not getting access to the services they need”.

The number of people who are HIV positive is growing. Indeed, the figure is up by 300 per cent in the past 12 years. The report by the AIDS Funders’ Forum says that the health needs of gay men and those over 50 are not being properly considered by NHS commissioners, who often have little knowledge about managing HIV effectively. A recent report by four bodies—the British HIV Association, the Royal College of Physicians, the British Association for Sexual Health and HIV, and the British Infection Society—says that HIV diagnoses are too often late, missed or simply wrong, and that inappropriate treatment is commonplace. The Terrence Higgins Trust published its annual survey in February. It found that almost half the number of PCTs had not assessed local sexual health needs for at least three years; prescribing restrictions were becoming more common; and sexual health issues such as contraception, HIV and abortion had assumed a lower profile in local health plans. There has been a loss of expertise in local sexual health planning, with the responsibility for commissioning shifting to non-specialist junior staff.

As if all that were not enough, research published in February by the Faculty of Family Planning and Reproductive Health Care reported that 40 per cent of sexual health clinics are having to reduce services, whether by accepting only a fixed number of patients or only seeing people with urgent problems. The vice-president of the faculty said:

“Patient care is suffering in community based sexual and reproductive health services ... Disinvestment and woefully inadequate IT systems are restricting client convenience and choice”.

Community contraceptive services contribute significantly to the training of professionals, which is one of the issues mentioned in the Question; but the faculty found that service cuts, understaffed clinics and high demand were not infrequently resulting in pressure on training activity.

Why is all this happening? The Government consistently tell us that sexual health is a priority. Indeed, in late 2004, John Reid announced £300 million of funding for sexual health services. As the noble Baroness, Lady Tonge, rightly said, much of that money has failed to reach the front line. The Department of Health’s own independent advisory group on sexual health and HIV reported last year that 45 per cent of PCTs had either withheld some or most of the new funding or absorbed the entire allocation into their general budget. The Chief Medical Officer, in his previous annual report, told us that public health budgets were being raided to pay off deficits elsewhere in the NHS. The Terrence Higgins Trust has recently amplified that; two-thirds of PCTs that responded to its survey said that Choosing Health money intended for sexual health services had been diverted elsewhere.

The Minister will no doubt tell us that it is up to PCTs to decide local priorities. If she does so, I would invite her to tell that to the patients up and down the country whose serious health needs are not being met by the NHS. Ministers should not shift the blame on to PCTs. In December, the chief executive of the NHS, David Nicholson, announced that not only was the NHS expected to balance its books in the next year, he also expected there to be a financial surplus in the health service by 2008. That pressure on the NHS to balance its books, alongside the abiding imperative to meet waiting time targets in acute care, has been a very significant driver behind the decisions by PCTs to divert funds away from public health services.

Even the central budgets for sexual health have been cut. Of the £300 million extra money announced in 2004, £50 million was to be spent on an awareness- raising campaign on sexual health. Last November, Caroline Flint announced a campaign worth only £4 million. When, in this Chamber, I asked the then Minister, the noble Lord, Lord Warner, what had happened to the other £46 million, he replied that it was,

“stored carefully in the coffers of the NHS”.—[Official Report, 21/11/06; col. 236.]

That makes one wonder what reliance one can place on any government announcement on future spending.

There are several specific issues that the Government could address now. The first is about the targeting of sexual health services. All the research tells us that there is a strong association between deprivation and teenage conceptions. The teenage conception rate in the most deprived wards in England and Wales is over four times that in the least deprived wards. Professor David Paton, at the University of Nottingham Business School, has said that the underlying social deprivation of an area, family breakdown rates and religion have a greater effect on teenage pregnancy rates than other more obvious policies. That tells us that access to family planning services cannot be the whole answer for this group of individuals. The Government’s steadfast refusal to reflect the value of marriage and the family in their wider policies could well be viewed as a contributory factor.

The National Institute for Health and Clinical Excellence has issued guidance that focuses on one-to-one interventions that aim to address the personal factors that influence an individual’s sexual behaviour and thus bring down the transmission of STIs and under-18 conceptions. The emphasis is on health professionals identifying those at high risk from disadvantaged communities and targeting interventions accordingly. That is sensible guidance from NICE; but one has to ask how on earth it can be implemented against the background of funding cuts that I have referred to. There really is only one answer here, unpalatable as it may be to the Minister, and that is to introduce some form of ring-fencing for this and other areas of public health expenditure.

I also respectfully draw the Minister’s attention to local safeguarding children boards and the protocols that they employ for working with sexually active young people. Last November, Brook and Action on Rights for Children sent out a survey to find out how LSCBs had implemented the Working Together guidance published by the Department for Education and Skills nearly a year ago. The survey found that a significant number of areas were introducing protocols requiring automatic referral to police and social services of all cases of sexually active under-13 year-olds. That policy produces the very opposite of what is needed: it deters young people from seeking the help that they need, sometimes desperately, because they know that they will immediately be reported to the authorities. The protocols that require mandatory reporting are inconsistent with the Working Together guidance, but they are nevertheless out there. Of the 70 LSCBs responding to the survey, 28 did not comply with the guidance. I ask the Minister: how has that situation been allowed to arise?

It is a great pity that this debate should have been consigned to a Friday afternoon. However, the Minister can be certain that for some of us in this House, the spotlight on these issues will remain fully on.

My Lords, I am grateful to the noble Baroness, Lady Tonge, for tabling such an important Question today, and she is clearly extremely well equipped to do so. I am also grateful to the noble Earl, Lord Howe, for being present. I must say that I do not recognise the bleak picture that he has presented, but I shall attempt to explain why. I understand that many noble Lords including my noble friend Lady Gould would wish to have been present, but the Question was tabled rather rapidly, hence their absence. That is why my noble friend Lord Hunt, the Minister, could not be here—he has a long-standing engagement that he could not break, and he sends his apologies.

The provision of contraception is a vital healthcare service which contributes to better maternal and child health. The cost benefit of contraception is well established and has been estimated at £11 for every £1 spent. It is also estimated that the prevention of unplanned pregnancy by NHS contraceptive services already saves the NHS over £2.5 billion a year.

This Government have made improving sexual health a key priority, including considerable new investment through primary care trusts. Reducing unintended pregnancies, improving access to contraceptive services and the full range of methods of contraception are crucial aspects of our overall sexual health strategy. Before I set out some of the actions we are taking nationally to support these goals, I wish to address the key concern that has been expressed today—that some clinics delivering contraceptive services in the community have been closed.

I have heard loud and clear the points that have been made and I well understand and share that concern. I understand that once a clinic has been closed, it is very difficult for it to be reopened. However, PCTs have been allocated resources to give them the freedom and flexibility to deliver on key targets, as well as financial balance. My own PCT in West Gloucestershire has increased expenditure by 9.9 per cent this year. It is not that the Government are trying to evade their national responsibilities; we are devolving power to PCTs. Ultimately, it is for those PCTs to determine the level of contraceptive service that they provide and from whom they commission those services to meet the needs of their local populations. Under the National Health Service Act 1977, a duty is delegated to PCTs,

“to meet all reasonable requirements … for the giving of advice on contraception, the medical examination of persons seeking advice on contraception, the treatment of such persons and the supply of contraceptive substances and appliances”.

I point out also that we have included sexual health and health inequalities in our six key priorities. This gives a clear direction to PCTs that, whatever else happens, they have to make progress on those key priorities and will be held to account for delivery on them. While the NHS budget will have almost tripled by 2008, I recognise that there have been real challenges for PCTs over the past year as the NHS has achieved financial balance. Contraceptive clinics have suffered and they should not be considered a soft option.

About three-quarters of the 4 million women using contraceptive services are seen each year by a GP. That leaves around 1.2 million women who attend community contraceptive clinics; that figure has remained constant over the past 10 years. Young women, in particular, prefer to use the clinics, and 16 to 19 years old is the peak age for attendance. The clinics play a crucial role in protecting against unintended pregnancies and sexually transmitted infections, as was highlighted in the White Paper Choosing Health: Making Healthy Choices Easier.

The availability of a well publicised, young people-centred contraceptive and sexual health advice service is a vital element of the strategy to reduce teenage pregnancies, which have such a profound effect on the lives of girls, especially, as the noble Earl pointed out, the most disadvantaged. There is a clear link between deprivation and teenage pregnancies. However, I refute his comment that the Government do not support marriage. We very much value the stability of marriage, but we also value other stable relationships.

The Government gave a commitment in the White Paper to undertake a baseline review of contraceptive services in England to identify gaps in local services and ensure that the full range of contraceptive services is available, that good practice is spread and that services are modernised. In January 2006, all PCT sexual health leads were asked to complete the baseline review of contraception services, thus providing a snapshot of service provision. The review incorporated a PCT questionnaire for use locally to identify gaps and areas for action, and nationally to provide a strategic overview of contraceptive services in England. Eighty-two per cent of PCTs completed the questionnaire.

Nationally, we have included centrally held information on prescribing data, rates of teenage pregnancies and abortion to provide a national picture of sexual health indicators pertinent to the provision of community contraception services. Contraception service commissioners and providers were advised to use the findings of the PCT questionnaire to address gaps in service provision locally in advance of the Department of Health publishing the findings, which we shall be doing very shortly.

My Lords, can the Minister be more specific about that? When will we have the results of the audit?

My Lords, I understand that it is ready for publication but, because of the purdah imposed by local government elections, it cannot be published until after those elections.

The results will also feed into best-practice guidance on reproductive health care, which is being drafted. This will be comprehensive guidance covering abortion and contraception provision, service delivery, professional roles and leadership, training and counselling for abortion. I understand that it will be published in the next few months, before the summer.

Last November, we launched a major media campaign on sexual health called “Condom: Essential Wear”. This is aimed at young men and women aged 18 to 24 and its purpose is to ensure that they understand the real risk of unprotected sex and to persuade them of the benefits of using condoms to avoid the risks of STIs and unplanned pregnancies. We have spent £6 million on the campaign in the past year. I know that that is not £50 million but it is a start. This is just one of three government campaigns working to improve sexual health and reduce teenage pregnancy. It complements the DfES's teenage pregnancy campaigns, “R U Thinking”, which is aimed at 13 to 16 year-olds, and “Want Respect? Use a Condom”, aimed at 16 to 18 year-olds. This integrated communications approach enables us effectively to target young people across the age groups. From some evaluation tracking, I understand that the messages really are getting through, the key messages being, “Don’t be pressured into having sex” and “Use a condom”.

One of our key aims is to improve access to the full range of methods of contraception. Expert opinion is that long-acting reversible methods of contraception—LARC—have a wider role to play in contraception and that their increased uptake could help to reduce the number of unintended pregnancies. The effectiveness of condoms and the contraceptive pill depends on their correct and consistent use. By contrast, the effectiveness of LARC methods does not depend on daily concordance. However, the uptake of LARC has been very low compared with usage of the contraceptive pill and other less reliable methods of preventing pregnancy.

The National Institute for Clinical Excellence published guidance on the use of LARC in 2005. This highlighted that these methods are more effective than the pill, and we strongly support that guidance. The use of LARC has been slowly increasing and it is encouraging that in 2005-06 it accounted for a fifth of all methods chosen. The noble Baroness is absolutely right that we need more training for LARC, and I understand that we are working with commercial partners to promote LARC methods in general practice, including training for the health professions.

Having children at a young age can damage young women’s health and well-being and severely limit their education and career prospects. The UK has a poor record on teenage conception, which is why we developed a 10-year, multi-faceted strategy on teenage pregnancy, which was launched by the Prime Minister in 1999. We also have a PSA target to halve the under-18 conception rate by 2010. The strategy is based on international research evidence on what works to reduce teenage pregnancy and improve health education outcomes for teenage parents and their children.

Teenage conception rates for under-18s have fallen by 11.8 per cent, and for under-16s by 12.1 per cent since 1998. While there has been steady progress nationally, there is huge variation in performance between areas. The best local authority has seen a reduction of over 40 per cent, whereas in some areas rates have increased. We know what works and have issued detailed guidance to local authorities and PCTs, setting out the key ingredients of successful local strategies. Recently, my right honourable and honourable friends—Beverley Hughes and Caroline Flint—had a meeting with the 22 areas in which there are the greatest number of teenage pregnancies, to try to encourage them to adopt all the best practice that is out there and cited in the guidance.

I shall move on briefly to the wider sexual health initiatives. Improving sexual health and access to genito-urinary medicine clinics is one of the top priorities for the NHS. Our key target is to ensure that, by 2008, everyone who needs an appointment at a clinic is offered one within 48 hours. Data recently published by the HPA shows that 70 per cent of patients were seen within 48 hours and a further 11 per cent were offered an appointment but chose not to attend. In May 2004, only 38 per cent of attendees were seen within 48 hours. Community contraception services can play a role in supporting delivery of this target as increasingly they are taking on more routine testing and treatment for STIs. The target is an opportunity to use levers, such as practice-based commissioning, to further develop the role of contraception services in this area.

Community contraception clinics already play an important role as a setting for screening young people between the ages of 16 to 24 in the National Chlamydia Screening Programme. More than 104,000 screens were undertaken in year three of the programme, and community contraceptive services remain the most common screening location for both men and women. The noble Earl is right to draw our attention to the fact that we have problems with chlamydia, and we must do everything that we can to ensure that more and more young people are properly screened.

The noble Earl raised the question of HIV, and I draw his attention to the fact that we have increased our investment this year and next year by £1 million in our targeted HIV health promotion for gay men and African communities, who are most at risk of HIV in the UK. We believe that targeting these groups is the most sensible way forward.

The noble Baroness mentioned the vital role of training. We are, of course, aware of the major role that specialist contraception services play in providing training and, in particular, the role they play in supporting general practice, so any reduction in these services may have an impact on the number of providers being trained. We also recognise that there is an urgent need to increase the numbers of sexual and reproductive health consultants, and the department is working closely with the Royal College of Obstetricians and Gynaecologists to address workforce issues.

We are committed to supporting training and competency development for contraception. For example, the Department of Health is funding the associate nurses working group of the faculty of family planning and reproductive healthcare to develop national recommended training standards in contraception, sexual and reproductive health for non-medical healthcare professionals. The standards and core package will be disseminated to all higher education institutions, commissioners and providers for use in ensuring provision of post-basic training in contraception and sexual health.

The noble Earl raised the question of IT. There are plans for the future inclusion of sexual health services in Connecting for Health. We are confident that this will be done. Clearly, however, there are difficulties of confidentiality which we are currently addressing.

Community contraceptive services undertake high quality and absolutely essential work. They do an excellent job, and I pay tribute to them, especially as they grapple with the challenges of a reformed and modernised health service. We will develop new commissioning guidance this year which will include commissioning of contraception provision. This and all the other actions I have highlighted today underline the Government’s commitment to ensuring continued access to high quality contraception provision, whether in general practice, community or voluntary sector settings. Contraceptive services are absolutely vital to the future economic and social well-being of our country, especially for those who live in the most deprived areas.

House adjourned at 2.01 pm.