Despite many examples of innovation in this part of the health system, we saw financial and other pressures having a real impact on patient care.
There is no doubt that GUM services are under pressure financially. The public health grant to local authorities was reduced by 6.7 per cent during 2015/16 with further reductions planned until 2020/21. Across England, spending on STI testing and treatment decreased by almost 4 per cent between 2013/14 and 2015/16, as local authorities implemented these cuts. The situation varies at a local level: around one in seven local authorities actually increased their spending by more than 20 per cent over that two-year period, while around one in four cut their spending by this amount. However, data on future spending plans shows cuts are set to deepen.
GUM is somewhat protected by regulations dating back to 1916 that mandate the provision of a comprehensive STI testing and treatment service. Other public health services which are not mandated have seen even deeper cuts.
Cuts to GUM spending are particularly worrying given the rapid rise in some STIs. Not only is demand for GUM services going up (the number of new attendances at clinics increased from 1.6 million in 2011 to more than 2.1 million in 2015), diagnosis rates for many STIs, such as gonorrhoea (up by 11 per cent between 2014 and 2015) and syphilis (up by 20 per cent), are also on the rise. That infection rates are increasing faster than attendances suggests incidences of STIs are increasing, rather than this just being about better detection.
What does this mean for patients? In some parts of the country we heard that clinics have been closed, moved to less convenient locations or their opening hours reduced. Some clinics are being run with less consultant input, which some see as an efficiency saving but others see as a safety concern. A recent survey shows that patients with STI symptoms are finding it more difficult to access appointments within 48 hours.
We were particularly concerned about cuts to health adviser posts in clinics. These are professionals trained in giving advice to patients newly diagnosed with infections, and in tracing and notifying current and past sexual partners so that they can be brought in for testing. We also heard about cuts to outreach services that target high-risk groups such as sex workers and men who have sex with men; and to sexual health advice, promotion and prevention services.
These changes have far-reaching implications. GUM is not only an important clinical service, it also provides a key public health function, stemming the onward transmission of infections to avoid them spreading among the population.
However, the picture is not all negative. There are exciting new innovations in sexual health such as online access to STI testing kits that allow patients to test at home and receive results quickly via text message. Local authorities are also working hard to get more value from their contracts. Although there is, as yet, little evidence on the strengths and weaknesses of this approach, they told us that they take a very different commissioning approach to their primary care trust (PCT) predecessors – one that involves more detail being put into service specifications, more scrutiny and more ongoing monitoring (seen as positive by some, and burdensome by others).
Reduced funding is not the only challenge for GUM services. The changes to commissioning arrangements for sexual health, reproductive health and HIV services, introduced in 2013, have confused accountability arrangements at local and national level. Both the Health Select Committee and the All-Party Parliamentary Group on Sexual and Reproductive Health have highlighted this as a major issue. Our forthcoming report and event on the future of HIV services will consider these issues in more detail.
We identified a number of factors that make sexual health services particularly vulnerable to financial pressures, including:
- the consequences of cuts are often long term and not immediately visible
- perverse incentives mean the cost of cuts often fall on other commissioners (HIV treatment is funded by NHS England) and other services (infectious diseases pass from residents of one local authority to another)
- the lack of accountability since 2013 means there is limited oversight and scrutiny
- many of these services are provided to hard-to-reach groups with little political voice.
With the ringfence on the public health budget set to be removed in 2019/20 (it has just been extended for a year) and the concurrent move to local business rate funding, what will the future hold for GUM and other public health services when cash-strapped local authorities are faced with tough choices about where to invest their scarce resources? The impacts of cuts to sexual health services are severe: in 2020 no one wants to see a situation where the current rapid rise in infection rates for some STIs has been sustained.