Sexual health services and the importance of prevention

Rhetoric about prioritising prevention is not new. There is solid evidence that it delivers a good return on investment in the long-run. But moving beyond rhetoric is challenging for a system whose gravitational pull is towards treating people in hospital. Despite being one of the new Secretary of State’s three key priorities, if you follow the money then prevention still lags way behind cure.

This is illustrated by changes in spending on public health. Between 2013/14 and 2017/18 the public health grant to local authorities decreased by 8 per cent in real terms from £2.7 billion to £2.4 billion (comparing spending on like for like services), while NHS England’s budget increased by over 10 per cent. Just before Parliament rose for the Christmas break, the government confirmed a 2.6 per cent cut in the public health grant for 2019/20. Services providing sexual health advice, prevention and promotion have been among the biggest losers from the decrease in public health spending, so this latest reduction signals further cuts are likely. Of course, the NHS and other areas of local government also spend money on prevention, but the public health grant is currently one of the main routes for investment in prevention, and funding levels are a key indicator of whether it is being prioritised (although, as I go on to discuss below, spending figures do not tell the whole story).

A closer look shows that the further upstream you go, the drier the river. Spending on services that provide primary prevention (averting the onset of disease) tends to get squeezed more than spending on secondary prevention (detecting and treating disease in its early stages) and ‘tertiary prevention’ (managing symptoms slowing the progression of an established disease).

You can see this in the data on sexual health services spend. Figure 1 shows that between 2013/14 and 2017/18 total local authority spending on sexual health decreased by 14 per cent in real terms from £668 to £572 million. This includes spending on STI testing and treatment (down by 10 per cent to £364 million), contraception (down by 15 per cent to £161 million) and sexual health advice, prevention and promotion (down by an eye watering 35 per cent to £47 million). These cuts are particularly worrying given recent rapid increases in some STIs like gonorrhoea and syphilis – currently a focus of a Health and Social Care Committee inquiry (you can read our evidence submission here).

Local authority spending on sexual health services

Notes: Data is final outturn. Real terms data in 2017/18 prices, based on HMT GDP deflators published 1 November 2018. https://www.gov.uk/government/collections/gdp-deflators-at-market-prices-and-money-gdp. Source: https://www.gov.uk/government/collections/local-authority-revenue-expenditure-and-financing#2018-to-2019

This national picture hides variation in the spending patterns of individual local authorities (Figure 2). Overall, 18 (12 per cent) local authorities increased their total spend on sexual health services over the period, while 133 (88 per cent) decreased it.

Figure 2: The majority of local authorities have reduced sexual health spending

There are some caveats to bear in mind when interpreting this data.

Definitional issues and changes in how sexual health services are organised and contracted have changed the way some local authorities report their spending data, and this affects some of the trends for individual service lines. For example, in some areas, a reduction in spending on STI testing and treatment might be due to a local authority reallocating that spend to the contraception budget line because they have integrated the two services into a ‘one stop shop’ .

Importantly, a spending reduction is not always a bad thing for local people – innovations can save money and maintain or improve service quality. For example, STI tests that can be ordered online have improved access for some and are cheaper than clinic-based appointments (although clinic access is still critical for those who need face to face advice and support). Despite budget cuts, sexual health clinics are doing more with less if you look at throughput: there was a 13 per cent increase in attendances at sexual health clinics between 2013 and 2017. However, although productivity improvements can offset the impact of spending reductions there are limits to how much this can happen before access and quality start to suffer, and our previous research shows budget reductions have started to cut to the bone in some parts of the country.

Despite these caveats, two clear conclusions emerge from the data. Spending on sexual health services has been cut in most parts of the country (and this was largely inevitable given reductions to the public health grant). And the biggest cuts are to upstream, primary prevention services that work to promote safe sexual behaviour. Our interviews with sexual health commissioners and providers in 2016 found that sexual health outreach and prevention was the area most frequently identified as a priority for extra investment, should more money become available.

This isn’t marginal stuff. Advice, prevention and promotion includes services that go to people where they are, like pop up stalls in colleges and clubs that provide condoms, STI testing kits and sexual health advice to at-risk groups. They also include support groups and peer mentoring programmes.

The services are often provided by small charities that are embedded in local communities and are experts in working with at risk-groups such as gay men or young people. Small charity leaders have told me that they often rely on local authority funding and once contracts end small charities can struggle to remain viable. This means a tactical decision to cut funding can have a long-term strategic impact on the local market for providing services.

I recently spoke to the chief executive of a charity that works with young people on sexual health and a range of other issues. She told me about a young man who started regularly visiting a pop-up stall they had in the local college to pick up condoms. Over the course of a few weeks, the advisor who worked on the stall got to know this young man and started to talk to him about his sexual relationships and other issues. The adviser identified some risky behaviours – he was in a relationship with a woman but having casual unprotected sex with various men – and connected him with the charity’s support service. Over time he told a counsellor that he had been sexually abused when younger, and they worked with him to unpick a range of issues, connecting him with services to address both his mental and physical health needs. For the first time, the different issues in his life were looked at together and he was given the support he needed. Services like this are providing really important support to vulnerable people with complex lives.

This is part of the broader approach that we advocate in our vision for population health, which argues that improvements cannot be delivered by the health and care system alone, and calls for more attention to be given to the wider determinants of health and the role of people and communities.

It will be difficult to shift the system’s centre of gravity towards this type of population health focused work, particularly in the context of budget cuts. That is why we have called on government to restore local authority public health funding to 2015/16 levels and move to multi-year settlements that allow commissioners to be more strategic and plan over the longer term. This shift will require strong political leadership from the Secretary of State to ensure population health is a key priority across government, and not just within the Department of Health and Social Care.

It’s never all about the money, but at the moment the money is so far behind the rhetoric that without a major change in policy, the Secretary of State is unlikely to live up to the title of the latest in a long line of strategies, that prevention is better than cure.