Sexual health services
In England, sexual health services are part of public health. This means that most ‘open access’ services (where people can use any sexual health clinic, in any area) are commissioned by local authorities rather than by the NHS. Responsibility for commissioning more specialized sexual health services, such as HIV treatment and care, is split between NHS England and integrated care systems (ICSs).
From 2023, there were 4.6 million consultations delivered by sexual health services in England. Except for a slight dip in 2019 to 2020, due to disruption to services during the covid-19 pandemic, the number of consultations has increased steadily over the last decade. The scaling up of online and telephone service provision has contributed to this increase.
Spending on local authority-funded sexual health services in England has reduced in real terms from £776 million in 2013/14, when responsibility for public health was transferred from the NHS to local authorities, to £547 million in 2021/23.
Sexually Transmitted Infections: Understanding Risks and Impacts
Sexually transmitted infections (STIs) are diseases, caused by bacteria, viruses, and parasites, that can be passed from one person to another through condomless sexual contact with an infected partner. Some STIs can also be transmitted to a baby during pregnancy, childbirth and breastfeeding. Other routes of transmission include sharing needles.
The prevention, diagnosis and treatment of STIs is vital to stop their onward transmission and to prevent the development of long-term health problems from undiagnosed and untreated STIs.
The chart below shows trends in the number of sexual health screens – diagnostic tests for chlamydia, gonorrhea, syphilis or HIV – and new STI diagnoses since 2015. In 2023, 2.4 million sexual health screens were carried out and around 402,000 new STIs were diagnosed. The pandemic disrupted sexual health screens and diagnoses, meaning there were fewer in 2019 and 2021 than in previous years, although numbers have since recovered.
Data on STI diagnosis indicates that young people; gay, bisexual and other men who have sex with men; and people from Black Caribbean ethnic backgrounds have disproportionately high rates of certain STIs.
In 2023, the most frequently diagnosed STIs were chlamydia, accounting for 49% of all new diagnoses, followed by gonorrhea at 21%. First episode genital herpes and genital warts each represented 7% of new STI cases.
Over the last 10 years, there has been a decrease in the number of new diagnoses of many STIs, but gonorrhea and syphilis have increased.
The number of gonorrhea diagnoses in 2023 was the highest since records began in 1918, while the number of syphilis diagnoses was the highest reported since 1948. There is also concern that gonorrhoea has developed resistance to certain antibiotics, limiting the treatment options available.
Human Immunodeficiency Virus (HIV)
Human immunodeficiency virus (HIV) weakens a person’s immune system and their ability to “fight everyday infections and disease”. HIV does this by destroying certain white blood cells (known as ‘CD4 cells’) that tackle infection.
HIV is treated using antiretroviral medicines (sometimes called antiretroviral therapy – ART). These stop the virus replicating in the body and allow the immune system to repair itself and prevent further damage. While there is currently no cure for Human Immunodeficiency Virus (HIV), ART is effective and can enable people with HIV to live a long and healthy life.
In January 2019, the government committed to achieving zero new transmissions of HIV in England by 2029 and, in 2021, put in place an action plan setting out how it would achieve this target.
This increase was largely explained by a rise in cases which were first diagnosed abroad. These infections were likely acquired abroad and therefore do not reflect a rise in transmission in England.
Reproductive Health and Well-being
The British Medical Association, however, notes that the reproductive health of a population is “typically measured by pregnancy related ‘morbidity’ outcomes such as rates of abortion or repeat abortion and teenage pregnancy”.
Conception rates among women of childbearing age in England have declined in recent years, with the data suggesting that the rate in 2021 was the lowest since 2001. Conception rates among girls under the age of 18 fell year-on-year between 2007 and 2020, before increasingly slightly in 2021.
There were 252,000 legal abortions carried out in England and Wales in 2022, which is the highest number ever recorded. Between 2012 and 2022, abortion rates increased for women of all ages, except for those aged 18 and below.
Sexual and reproductive health: overview
Sexual and reproductive health’ covers a broad range of health matters, from sexually transmitted infections (STIs) and contraception to relationships and conception. It is an important aspect of the overall health and wellbeing of both individuals and communities.
The Department of Health and Social Care (DHSC) has adopted the World Health Organization’s (WHO) definition of sexual health. This views it not simply as the “absence of disease, dysfunction or infirmity “but rather positive wellness:
A state of physical, emotional, mental and social well-being in relation to sexuality Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
The WHO also emphasizes that good sexual health depends on access to:
⦁ comprehensive, good-quality information about sex and sexuality
⦁ knowledge about the risks individuals may face and their vulnerability to adverse consequences of unprotected sexual activity
⦁ sexual health care
⦁ an environment that affirms and promotes sexual health.
Poor sexual health can have numerous consequences. STIs, for example, are a key contributor to poor health. They are often asymptomatic and can have a direct impact on both sexual and reproductive health (particularly if they are left untreated) through “stigmatization, infertility, cancers and pregnancy complications and can increase the risk of HIV”.
There is also a risk of transmission to others. In the case of syphilis (an STI caused by the bacterium Treponema pallidum), there may be life-threatening neurological and cardiovascular complications if it is left untreated.
Other consequences of poor sexual and reproductive health include:
⦁ unplanned pregnancies and abortions
⦁ psychological consequences, including from sexual coercion and abuse
⦁ poor educational, social and economic opportunities for teenage mothers, young fathers and their children
⦁ HIV transmission
⦁ cervical and other genital cancers
⦁ hepatitis, chronic liver disease and liver cancer
⦁ recurrent genital herpes
⦁ recurrent genital warts
⦁ pelvic inflammatory disease, which can cause ectopic pregnancies and infertility
⦁ poorer maternity outcomes for mother and baby.
England’s Sexual Health Strategy
The most recent sexual health strategy was published by the Department of Health in March 2013. ‘A Framework for Sexual Health Improvement in England’ set an ambition to “improve the sexual health of the whole population” and to:
⦁ reduce inequalities and improve sexual health outcomes
⦁ build an honest and open culture where everyone can make informed and responsible choices about relationships and sex; and
⦁ recognize that sexual ill health can affect all parts of society – often when it is least expected.
Comprehensive Sexual and Reproductive Health Services
In England, sexual health services are part of public health. This means that most services are commissioned by local authorities rather than by the NHS. The development of this commissioning model follows the transfer of most of the public health to local government in 2013 under the Health and Social Care Act 2012. For further information on public health and local government see section 10 of the library briefing on the structure of the NHS in England.
Open access sexual health services
Local authorities are responsible for commissioning open access sexual health services including:
⦁ Most contraceptive services and all prescribing costs, but excluding GP additionally provided contraception (see below for further explanation)
⦁ STI testing and treatment, chlamydia screening and HIV testing
⦁ Specialist services, including young people’s sexual health, teenage pregnancy services, outreach, HIV prevention, sexual health promotion, services in schools, college and pharmacies.
The service models used by local authorities to deliver sexual health services vary across England. The UK Health Security Agency (UKHSA) notes that there are:
For example, under the GP contract, GPs provide ‘essential services’; these are mandatory for all GPs to deliver to their patients. GPs can provide other clinical care, known as ‘additional services. ‘Contraceptive services’ are defined in the GP contract as ‘additional services and most GPs do provide.
them. If GP practices opt out of providing contraceptive services, they will receive a deduction in funding and NHS England is required to commission the services from another provider.
Certain types of contraception, however, are deemed to be an ‘enhanced service’. This includes contraceptive device fittings and injectable contraception. GPs can, but are not required, to offer enhanced services; additional funding is provided if enhanced services are offered, but there is no deduction in funding if they are not offered. Provision of these services therefore varies locally.
To tackle local disparities in service provision, the Office for Health Improvement and Disparities, along with the UK Health Security Agency, has released an ‘Integrated Sexual Health Service Specification.’ This document emphasizes that services should be tailored to meet the specific needs of local populations and aim to reduce inequalities in access and health outcomes.
Specialized Sexual and Reproductive Health Services: Enhancing Care and Access
Responsibility for commissioning more specialized sexual health services is split between NHS England and integrated care systems (ICSs, of which there are 42 across England).
ICSs commission:
⦁ most abortion services
⦁ sterilization and vasectomy
⦁ non-sexual-health elements of psychosexual health services
⦁ gynecology, including any use of contraception for non-contraceptive purposes.
NHS England commissions:
⦁ contraception provided as an additional service under the GP contract
⦁ HIV treatment and care
⦁ promotion of opportunistic testing and treatment for STIs and patient requested testing by GPs
⦁ sexual health elements of prison health services
⦁ sexual assault referral centers
⦁ cervical screening
⦁ specialist fetal medicine services.
Some have identified the division of commissioning responsibilities between three sets of organizations (local authorities, ICSs and NHS England) as presenting difficulties to the users, providers and staff of sexual health services. For example, the Health and Social Care Committee said, in its 2019 report on sexual health, that the 2012 act had broken up “interlinked services into [three] different silos” which, in turn, had “led to a greater number of system boundaries, relationships and funding pots to negotiate”.
Public Health England (PHE) acknowledged in its 2017 review of sexual health commissioning that commissioning arrangements were viewed as complicated, complex and fragmented by those responsible for sexual health services.
The Health and Social Care Committee reported that while efforts had been made to address these problems, the evidence it received “was clear that fragmentation remains a significant obstacle to effective commissioning”.
Appointment Waiting Times in Sexual Health Services
Guidelines published by the National Institute for Health and Care Excellence (NICE) state that people contacting a sexual health service about an STI should be offered an appointment, or the option to attend a walk-in clinic, within two working days. 30 There is not an equivalent waiting time standard for accessing all sexual health services for other reasons.
In 2023, the Terrence Higgins Trust, a sexual health charity, highlighted a significant gap in data reporting, noting that “no data currently being reported in any of the nations about waiting times” for accessing GUM services. The last recorded monitoring of waiting times for GUM clinic appointments by the (then) Department of Health was in November 2011, which revealed that “89% of individuals visiting a sexual health service for the first time were offered an appointment within 48 hours across Great Britain.”
A ‘mystery shopper’ exercise, conducted by the Terrence Higgins Trust, examined average waiting times for appointments at sexual health clinics in November and December 2022. It found that waiting times for face-to-face appointments (available to book by telephone) “averaged 13 days, rising to 19 days in rural parts of England”. It also found that face-to-face appointments were offered by 51% of sexual health clinics who were contacted by telephone.
Coverage for cervical screening refers to the proportion of those eligible who have received a test within the recommended time-period.
In the 2022/23 financial year, approximately 16 million people in England were eligible for cervical screening, of which 11 million had been screened within the appropriate period. This equates to a coverage rate of 68.7%. Total coverage has fallen since the start of the pandemic, from 72.2% in 2019/20.
Coverage varies across different regions in England, ranging from 61.3% in London to 72.5% in the Northeast in 2022/23.
