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APPG Enquiry on Contraception: Joint Submission from ADPH, LGA and EHSHCG

Consultations | March 29, 2019

Dear Colleague,
APPG Enquiry on Contraception: Joint Submission from the Association of
Directors of Public Health, Local Government Association and English HIV and
Sexual Health Commissioners Group
We write jointly following your invitation to us as bodies representing commissioners in
England. We are obviously happy to provide oral evidence in addition to this.

Key Points
We would want to make some points which we believe are key to ensuring an effective
system for commissioning and provision of contraception moving forward.
1. We support a whole system approach bringing together reproductive health,
sexual health and contraception which encompasses services and
commissioning, strategic approach and health promotion.
2. It is vitally important that people are able to access good quality information on
their reproductive health from sexual health services and that they can access
the full range of contraceptive choices.
3. Contraceptive needs change across the life course and services should be able
to support women and men throughout their lives:
4. The evidence base shows that the most reliable forms of contraception are long
acting contraceptives – implants and coils. The strategy adopted by
commissioners over recent years has been to promote and increase access to
Long Acting Reversible Contraception (LARC) rather than user-dependent methods of contraception and research suggests that the increased uptake of LARC has been a significant driver of reduced rates of teenage pregnancy.
5. For working aged adults, access to contraception remains important and needs
to be universally accessible, recognising the need for access outside of working
hours. It is concerning that whilst over the last 10 years, abortion rates have been
decreasing for women under 25, they have been increasing for women aged 30
and over.
6. Finally, specific issues (such as natural decline in fertility, change in long term
partners) place a continued need for tailored prevention advice and access to
effective contraception for older people.
7. Sexual and reproductive health is about wellbeing, not just services. Education,
personal capacity and resilience, good relationships and preventative actions are
as important as the provision of high quality sexual and reproductive health
8. Commissioning, planning and providing sexual health services is undertaken in a
challenging complex environment making relationships between services and
systems critical.
a. Demand for sexual health services including contraception services is
continuing to grow (attendances at sexual health services have increased
by three percent in the last year and by 13% over the last five years). The
LGA recently published Local Government Delivers which provides more
data on these, a copy of which we attach to this letter.
b. At the same time public health funding in England will have been cut by
£700 million between 2014/15 and 2019/20
c. Councils are striving to manage the increasing demand and budget
reductions so that they don’t impact on service quality
d. We know that investing in contraception services delivers a return on
investment – every £1 spent on contraceptive services saves £9 across
the public sector but the cuts by government are a totally false economy
e. The Government must make significant and sustainable investment in
public health a priority in the spending review
9. We acknowledge that there is currently fragmentation in
commissioning, it is important that commissioners work together to
reduce fragmentation.
a) Fragmentation was a feature of the system long before the transfer of
services in 2013 and this was pointed out by a number of reports.
Fragmentation has also created issues around commissioning and access
to LARC for non-contraceptive purposes. Some areas have resolved this
through joint commissioning arrangements between LAs and CCGs.
b) In support of our assertion of this, we would draw your attention to several
national reports on fragmentation prior to the transfer of responsibilities in
i. In 2004 the National Manual for Sexual Health Advisers
described a history of service fragmentation.
ii. The Department of Health’s 2008 Gender and Access to Health
Services Study described fragmentation across services for
many people, including reproductive and sexual health.
iii. A 2010 report for NICE concluded there was fragmentation in
sexual health and reproductive care for pregnant women.
iv. The European Forum for Primary Care in 2010 concluded that
sexual and reproductive health fragmentation was a problem
across Europe.
v. The Royal College of Obstetritians and Gynaecologists in 2011
concluded that Womens’ Health especially reproductive and
sexual health was fragmented and not joined up.
c) We believe that moving responsibilities around for commissioning would be
a false economy, a distraction and cost more in time and money than simply
ensuring all partners agreed to work together around a pathway. We do not
need structural reorganization, we need a collective change in the way
commissioners behave.
10. Sexual health commissioning and services should embrace the introduction of
evidence-based innovative technologies and digital services and this will require
training, funding and evaluation.
11. We would want to see an increased uptake of LARC.

A whole system approach
We believe that a whole system approach needs to be taken at both the local and national
levels, covering prevention, improvement, promotion and protection, and spanning the
three areas of sexual health, HIV and reproductive health including contraception.
Attempts to tackle these issues in isolation will lead to silo working and will not be
representative of people’s experiences of sexual health, which are not divided into the
three categories. This means that further transfer of commissioning responsibilities and re-organisation is not the answer.
We would argue that in the face of significant challenges, local authorities have attempted
to ensure services continue to provide access within available resources. Public Health
England in submitting evidence to the Health and Social Care Select Committee recently
emphasised that there had been significant use of the local authority role and assets such
as early years, youth services, substance misuse and community assets. These can be
made to encourage the adoption of a positive approach to reproductive health, and
investment is needed to ensure reproductive health continues to be well commissioned,
and accessible.

Sustainability and Transformation Partnerships
Sustainability and Transformation Partnerships (STPs) in England provide an opportunity
to take a systems approach to sexual health and work closely together to create a more
coordinated service for patients, providing links into pathways for contraception services
and other services such as early pregnancy assessment, abortion services, maternity
services and health visiting.
General practice is often the first point of access to healthcare for people, this is also the
case for many women accessing contraception services. The close collaboration between
local authority and NHS commissioners to ensure that the full scope of contraceptive
choice is available at GP surgeries is essential. There are good examples of joint working
by local authority and CCG partners, particularly in ensuring a joined up approach to GP
contraception services.
It is important that surveillance systems continue to be supported and
that the role of the voluntary sector partners in outreach services is
promoted. Local authorities are well placed to commission and deliver a
positive approach to sexual health and work more closely together to create a more
coordinated approach to sexual health and create a more coordinated service for patients.
Greater use of the local authority role and assets such as early years, youth services,
substance misuse and community assets can be made to encourage the adoption of a
positive approach to sexual health and contraception services.

Public health funding
Public health funding in England will be cut by 9.7 per cent by 2020/21, £331 million in
cash terms, in addition to the £200 million in-year cut for 2015/16.15 Although Directors of
Public Health (DsPH ) have been acting to manage these cuts, through modernising
services and introducing innovative online services, they have reached the limit of
available efficiencies. Cuts to public health funding may result in cuts to sexual health
services. In our Public Health System Survey 2017, we asked Directors of Public Health
about recent and planned changes to services. 16 51 per cent of respondents had
redesigned their sexual health services within the last year and 18 per centhad changed
the provision. Sexual health services were the most commonly redesigned public health
service and 50 per cent thought that redesigning or changing provision had had a positive
impact on the service.

Current Situation
We believe the work we are doing is having a positive impact. We have seen increases in
total prescribed LARC, GP prescribed LARC and SRH prescribed LARC at a national
level. While we welcome this, we are seeing reductions to Government funding. At the
same time:
1. There has been no significant increase in the total abortion rate
2. Teenage conception rates have continued to decrease and are now at the
lowest recorded level
3. Greater moves towards more integrated sexual health services has improved
access to SRH services and enabled more people to have their contraception
and STI needs met in one service and/or in one appointment
4. In a number of areas access to LARC has been increased
through the delivery of LARC within primary care extended
hours services provided by GP alliances and networks
Having said that, we recognise there remain some continuing challenges:
1. Anecdotal evidence from some areas that women are finding it increasingly
difficult to access contraception in primary care (due to GP capacity) which is
increasing demand for contraception on specialist SRH services
2. In response to PH Grant reductions some LAs have been forced to introduce
age restrictions on pharmacy EHC services and/or concentrated resources into
a smaller number of higher volume providers
3. Some GP LARC providers have stopped providing LARC in some areas due to
other demands on primary care
Progress since the transfer of commissioning in 2013
Public Health England concluded that sexual health has more attention and focus in the
local authority as it represents a large share of PH grant expenditure than it did within the
NHS. Sexual health services accounts for over 25 per cent of the entire public health
expenditure of English local councils There is therefore greater focus and scrutiny of
spend, and significantly increased transparency, which has led to improved leadership,
more innovation, improved access (through integration, digitalisation and co-location with
other PH services in some areas) which has delivered improved sexual health outcomes
and better value for money. A series of case studies showcasing these are currently being
prepared for publication.
We believe that as a result of the transfer of commissioning:
1. SRH Services are now better commissioned: with service
specifications, performance monitoring and are more
appropriately costed and funded.
2. There is greater integration with broader local authority services rather than just
a focus on health service for example, exploitation, safeguarding, education,
social care (LAC), youth service and youth offending services.
3. We have seen the development of and improved access to more modern
integrated SRH services rather than former family planning services which were
often seen as ‘Cinderella services’ within the NHS.
4. There has been an increased development of more one-stop shops. While some
clinics may have closed, this has often led to better quality services and
improved access often out of hours e.g. evenings and weekends, which were
not a feature of former services in the main.
5. We have seen more Nurse led provision which is also more cost-effective.
6. We have seen a significant increase in digital provision and targeting of more
vulnerable residents, including those accessing services for the first time.
7. We have seen more collaborative commissioning between local authority and
Local Authorities have had to take leadership of the local sexual health commissioning
system. This has been successful in some areas where relationships between
commissioning organisations are strong but performing less well in others, particularly
where there are large numbers of CCGs and/or where relationships between
organisations are complex and under-developed. The key to resolving this is to ensure
there is investment in public health, and to make sure everyone works together, not to
produce a further reorganisation of commissioning responsibilities.

Key issues and barriers that need to be addressed
1. Lack of transparency, accountability and performance
management of GP contraception provision as part of NHS
GP contracts leading to geographical variation.
2. Lack of engagement from NHS England and the CCGs in some areas due to
other pressing priorities.
3. Some CCGs making decisions in relation to the provision of vasectomy and
female sterilisation services which increases demand for LA commissioned
contraception services.
4. Some CCGs making decisions not to include the provision of contraception
within termination of pregnancy services.
5. Out of area cross charging for contraception remains complex and contentious,
particularly as services become more integrated, as this was not previously
cross charged within the NHS system.
6. Cervical screening within SH services is problematic in many areas.
7. NHS England commissioning is too distant at a local level and there has been a
lack of effective engagement with LAs in the commissioning of HIV treatment,
cervical screening, Sexual Assault Referral Centres (SARC) Service and prison
sexual health services.
8. More progress has been made with CCG commissioned sexual health services
as they are commissioned at a local level.
A further challenge is where investment/spend by one organisation (e.g. LA) leads to
savings being received within another organisation (e.g. CCG, NHSE). Gain share
agreements could be a potential solution to this

We believe there are readily available solutions to these, provided the
investment in public health and contraception is secured:
1. Investment in public health must be increased. Cuts to public health budgets
must be reversed and public health needs to be funded both sustainably and
adequately in line with local population health need.
2. The recommendations of the Sexual Health, Reproductive Health and HIV: A
Review of Commissioning report need to be fully implemented. At the national
level this will include revising current commissioning guidance, facilitating sexual
health networks, developing a framework for sector-led improvement (SLI) for
sexual health and enhancing commissioning support tools.
3. In England, a clearer national approach should be introduced to fund out of area
activity for both genitourinary medicine (GUM) and contraception with payment
systems that support accountability and reduced administrative processes.
4. National bodies should prioritise support for the introduction of innovative
technologies and digital services, building on successes such as self-sampling
HIV testing. This will require adequate training and adequate funding.
5. All providers and commissioners/service planners should work together locally
to promote a whole systems approach to:
a) Develop models for integrated commissioning, and service provision
b) Seamless, affordable service pathways
c) Strong area-based networks and partnerships
d) Address barriers to primary care
e) Promote system led improvement
6. All sexual health commissioners and service planners should address health
inequalities and cultural and behavioural influences on health choices such as the stigma associated with sexually transmitted infections and
diseases, such as HIV.
7. At the local level, implementation of the Sexual Health, Reproductive Health and
HIV: A Review of Commissioning report will involve developing a model of ‘lead
integrated commissioning’ in each locality and testing models of local delivery
based on local practice. This may include:
a) Development of more Strategic SRH Commissioners Groups over several
LAs and CCG areas, where this makes local sense.
b) Collaborative Commissioning groups established in some areas to address
issues and barriers including the use of statutory instruments to transfer
sexual health commissioning functions or responsibilities between
organisations, where appropriate.
c) Development and use of Section 75 agreements between local authorities
and CCGs for the provision of LARC for both contraception and noncontraceptive purposes.
8. Actions should be taken to put into place effective preventative strategies such
as integrating GUM, HIV and contraceptive services to reduce the incidence of
STIs contraction and promote contraceptive choice.
9. Further integration of Contraception and Termination of Pregnancy of services .
10. Development of gain share agreements in some areas between LAs and CCGs.
We remain committed to ensuring effective access to contraception. We believe we have
delivered some improvements despite cuts in funding which would not have happened
without the transfer to local authorities.
It is also evident that if we wish for good contraception services, everyone with an interest
needs to call on government to ensure these are properly funded. Moving deckchairs and
responsibilities is not the most important solution. Funding is.

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