Cuts to sexual health services are putting patients at risk, says King’s Fund
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1328 (Published 14 March 2017) Cite this as: BMJ 2017;356:j1328
Cuts to sexual health services in parts of England are placing the care of patients at risk, a new report has warned.
The research by the healthcare think tank the King’s Fund concluded that budget cuts of more than 20% to genitourinary medicine (GUM) services in some parts of the country had led to service closures and staffing cuts that have harmed patient care.1 Experts said that the findings were particularly worrying given that numbers of diagnoses of sexually transmitted infections such as syphilis and gonorrhoea were rising.
Current pressures on services were also having a negative effect on staff morale and leading some staff to consider alternative careers, the report warned.
The researchers analysed data and interviewed frontline staff to examine the effect of funding pressure on patient care across four service areas: GUM, district nursing, elective hip replacements, and neonatal care (box).
Their findings indicated that sexual health and district nursing had been hardest hit, which the researchers said undermined the vision set out in NHS England’s Five Year Forward View to strengthen prevention and community based services.
The authors said that sexual health services such as GUM had become more prone to budgetary cuts since moving from the NHS to local government, because of local authorities’ legal obligation to balance their books. Authorities’ overall spending on GUM across England fell by 3.5% between 2014-15 and 2015-16. But within this there was substantial variation: around a quarter (36) of the local authorities cut spending on GUM by more than 20% between 2013-14 and 2015-16, whereas around one in seven increased spending by more than 20% in the same period.
The researchers found evidence of GUM services being tendered with “significantly lower budgets,” resulting in clinics being closed, moved to less convenient locations, or operating with reduced opening hours. The study cited examples of clinics moving from walk-in to appointment only services because of high demand, of local authorities refusing to pay when their patients attended clinics outside the local area, and of patients being unable to receive long acting reversible contraception for heavy menstrual bleeding.
Interviewees said that cuts had led to GUM clinics having to “significantly reduce” the level of input by consultants, with some reporting that no consultant was available on site at certain times of the week. They also reported cuts in health adviser posts and prevention, sexual health promotion, and outreach services targeted at high risk groups, all against a background of rising demand.
The report acknowledged that shifting sexual health services to local government had resulted in a stronger focus on value for money and that financial pressure had “stimulated innovations” such as the introduction of home sampling kits that can be ordered online.
But it said that the fragmented commissioning arrangements (box) had led to disjointed services and lack of clarity over accountability.
Mark Lawton, a consultant in sexual health and HIV and chair of the British Association of Sexual Health and HIV’s media group, said that budget cuts in parts of England were undermining patients’ access to “high quality, specialist sexual healthcare.” He added, “Staff have had to be cut from these services. The most expensive ones are the consultants, but those are the ones who have all the expertise.”
John Middleton, president of the UK Faculty of Public Health, said that the rising incidence of sexually transmitted infections suggested that more rather than less investment in GUM was needed. He said, “Early intervention by GUM services provides effective treatment for the individual but also reduces the risk of secondary cases: treatment is also prevention.”
Jane Dickson, vice president of the Faculty of Sexual and Reproductive Healthcare, said that the pressures outlined in the report were “being mirrored” in the delivery of contraceptive care. “Ultimately, this is resulting in restrictions of access to, and provision of, contraception and impacting on the quality of care and breadth of choice that patients are able to exercise over their sexual and reproductive health,” she said.
Problems identified in the four services assessed
Genitourinary medicine services
Public health budgets were cut by £200m (6.7%) in 2015-16
Around a quarter of local authorities cut GUM spending by more than 20% between 2013-14 and 2015-16. Around one in seven increased spending by this amount
The commissioning of sexual health, reproductive health, and HIV services has been split between local authorities, CCGs, and NHS England, resulting in fragmentation
New attendances at clinics rose from 1.6 million in 2011 to over 2.1 million in 2015
“You give a blank sheet of paper to local government to do something really exciting, and then you take the money away”—consultant
District nursing services
Community health services are particularly vulnerable to financial pressure, as they are funded by block contracts not directly linked to the activity
The number of district nurse posts fell by almost half between 2000 and 2014; vacancy rates are 20% or more
Demand for services is increasing because more older people are living with frailty and multiple long term conditions and because of the push for more care to be offered in the community
Shortages of GPs in out-of-hours services mean that district nurses are completing tasks traditionally undertaken by GPs, such as certifying deaths
Some providers are trying to reduce demand by tightening access criteria
Non-urgent referrals face increasing delays
Staff are working more than their contracted hours, and very intensely, increasing stress
“If a ward is full, a ward is full, but within district nursing caseloads there’s no way of doing that. The referrals keep coming, and providing they are appropriate in terms of clinical requirements, then those patients will be accepted”—national stakeholder
Elective hip replacement services
National tariffs have been cut by an average of 1.6% a year since 2010-11, while NHS specific inflation has risen, resulting in a real terms cut in the payments that hospitals receive per patient of 3.8% each year
Some commissioners have moved from tariff based to block contracts. Others are using prime provider contracts, where the provider is liable for the costs of operations, creating an incentive to treat patients in the community
The number of procedures rose by 90% between 2000-01 and 2015-16
Commissioners are trying to reduce demand by tightening referral criteria, such as by requiring obese patients to lose weight and smokers to quit
High levels of bed occupancy across hospitals have led to an increasing (albeit relatively small) number of operations being cancelled
There were 1% fewer hip replacements in 2015-16 than in 2014-15
In October 2016, patients waited a week longer for treatment than in the previous year, and 45% more patients are waiting longer than 18 weeks
“While [elective] patients are often in pain, their situation often isn’t life threatening, so . . . quite often more of [our] activity gets cancelled”—surgeon
Neonatal services
Staff shortages are the greatest challenge
Separate commissioning of neonatal (by NHS England) and maternity services (by clinical commissioning groups) hinders neonatal service commissioners from changing maternity services, which could improve outcomes for neonates. This also encourages CCGs to shift activity to neonatal services
Neonatal critical care activity rose by 10% from 2011-12 to 2015-16
The proportion of neonatal admissions at term increased from 56.6% in 2011 to 58.3% in 2013. It has been suggested that trusts may be incentivised to refer higher risk babies because the maternity tariff does not cover the cost of their care
High occupancy rates led to 10% of babies being transferred to another unit in 2015, with 18% going out of area
“Where the pathway crosses between CCGs and NHS England, it’s very difficult not to have the various incentives for pushing activity one way or the other. And our CCGs are so stretched financially. I’m sure it’s driving some of the growth in specialised services”—commissioner