Special Report: Let's talk about sexual health

It may not be apparent to the young person accessing a chlamydia screening programme or picking up condoms from her local clinic, but the way sexual health services are delivered changed in April this year. Local authorities have replaced primary care trusts (PCTs) as the bodies responsible for public health. This includes the commissioning of a raft of services including contraception, testing and treatment for sexually transmitted diseases, HIV prevention and sexual health promotion.

Jonathan McShane, lead on sexual health at the Local Government Association, describes the transition as "a long time in the making, but also a bit of a rush". The publication of government guidance on what is expected from sexual health services, A Framework for Sexual Health Improvement in England, was delayed no less than seven times over 21 months. It finally saw the light of day in March, only a month before local authorities took the reins.

McShane says local authorities, often lacking timely information from PCTs, have tended to play safe and extend existing contracts. So, on the ground, the same services are being delivered by the same providers. In the near future, however, more councils under the leadership of the new directors of public health will start to put services out for tender.

Providers of sexual health services for young people have expressed some fears about the transfer to local authorities. Young people might prefer to access a service away from their local area for privacy reasons, or because they have found a service elsewhere that is better tailored to their needs. There are concerns over how that will work now that local authorities are footing the bill. "A young person from, say, Cumbria may visit London and need to get a test while they are here," suggests McShane. "Providers are worrying how they are going to get paid - what is Cumbria's reaction to receiving an invoice with little information on it about the young person, perhaps just a postcode?"

Many providers feel the host borough should pay them for the service they provide, and then chase the money back from the home council. McShane says local authorities do not have the resources to do this, but Department of Health guidance recommends that the provider must get payment directly from the home council. The guidance also covers pricing - the home council will have to pay whatever the host local authority has negotiated with the provider.

Health and wellbeing boards, which were established by the Health and Social Care Act 2012, now drive the commissioning of sexual health services. They do this by carrying out local needs assessments and producing a health strategy to meets those needs, which in turn informs the commissioning of sexual health services, among other things.

"There is a lot of stuff we have got used to over the past few years that will fall by the wayside," predicts Professor Roger Ingham, director of the Centre for Sexual Health Research. "Commissioning will be more geared to who can deliver clinical services at what cost, and I am worried about the future of preventative services." Ingham fears the pressure of bidding for tenders and delivering targets will lead to organisations rushing young people through tests for sexually transmitted infections, rather than taking time to counsel them and give advice. "It is very important to allow time for a young person, who may be being pressured, to talk - there needs to be time to build up trust," he says.

Catering for the young

Frances Perroe is project lead at the Association for Young People's Health. She says her organisation is worried that local authorities will cut young people's services or amalgamate them with adult provision. "Young people don't have a very loud 'patient voice' and are less vocal in campaigning for services than older groups," she says. "However, it is their age group that is most in need of good sexual health provision."

The association recently delivered a project in partnership with the University of Bedfordshire to support young people in identifying the health and wellbeing issues faced by those affected by sexual exploitation. The young people trained themselves up as health advocates and produced a film exploring some of the issues they face. The National Children's Bureau is also running Lessons in Love, a programme of sex education targeted at children most likely to suffer sexual exploitation.

Jules Hillier, deputy chief executive at sexual health advice charity Brook, stresses that young people's specific needs must be addressed. "In some areas, there is a real focus on targets and less of an understanding of what young people need. We often have to fight to make the case that young people need a different approach. Thinking about young people's needs over targets and budgets is a real challenge in this climate."

She adds: "We do have concerns about the impact of the political environment of a local authority, given that councils are elected. If there is an area where the movement is against young people's sexual health services, this could have an impact on the commissioning of services."

Brook has joined forces with the charity FPA to run a campaign, under the banner "XES - We Can't Go Backwards", which aims to highlight the effect of funding cuts, policy changes and "aggressive opposition" on the availability of contraception. The campaign forms the basis of this year's Sexual Health Week, which runs from 16 to 22 September. Hillier says the charities will be putting "more focus on young people and how they are accessing services, and how more young people can engage with the campaign".

Justin Hancock, sex educator and founder of Bish Training, believes too much commissioning is designed to meet policymakers' ideas of what is necessary, rather than what young people actually need. "The agenda of commissioners and preventative projects at the moment seems to be dominated by child sex exploitation and gangs," he says. "When I started back in 1999, it was all about teenage pregnancy, there was a lot of money attached and a lot of really good work was being done. Then it became about chlamydia screening, and now commissioning seems to be tackling exploitation of children and young people by gangs or groups because of high-profile cases such as those in Derby and Rochdale."

Hancock is concerned that the kind of "one issue" projects that are being commissioned and funded have too rapid a turnover to achieve long-term benefits. "Projects don't get long enough to achieve what they need to - when a new target comes along, they get ditched. What needs to be commissioned are more flexible, long-term, high-quality sex and relationships education projects that can cover these and other important issues that need to be covered."

He adds: "Another recent political issue is porn and sexualisation. But that is not something young people are talking about in the way policy makers think they are. I work with young people who are having or thinking about having sex for the first time and what they want is sex education about their lived experience."

Council cuts and recruitment freezes have resulted in a lack of expertise within local authorities, with fewer workers on the ground to deliver schemes. Government guidance says a quarter of the public health money being transferred to local authorities should be used for sexual health services, but this is not mandatory.

Young people's sexual health certainly appears to be a priority for the Department of Health. Its framework's key ambitions include "build knowledge and resilience among young people", "improve sexual health outcomes for young adults" and "prioritise prevention". Moreover, two of the three indicators that will be used to monitor local authorities' delivery of sexual health services relate directly to young people: under-18 pregnancies and diagnoses of chlamydia in 15- to 24-year-olds.

But Lucy Emmerson, co-ordinator of the National Children's Bureau's Sex Education Forum, says there are inconsistencies between health and education policies: "The National Curriculum proposals will undermine the government's own ambition that all children and young people receive good quality sex and relationships education. The Framework for Sexual Health Improvement talks about a culture of openness on sex, sexual health and relationships, but this is not mirrored in the National Curriculum."

Although the framework states that "all children and young people should receive good quality sex and relationships education at school, at home and in the community", Emmerson says there is no indication in the framework as to whose responsibility that is, and that schools are not following through.

While sex and relationships education is statutory in maintained secondary schools, academies have more freedom, although they do have to pay "due regard" to government guidance on sex and relationships education.

Emmerson is particularly concerned that the new science curriculum, currently in its final draft version before imminent publication, has lost any mention of sexual health. "The government says it would expect sexual health to be taught as part of reproduction in the new science curriculum, so we think that is what it should say in the National Curriculum itself, otherwise it will be up to schools to choose if they teach sexual health," she says. "We believe that learning about sexual health must be guaranteed."

Education improvements

An Ofsted report published in May found that sex and relationships education required improvement in a third of schools. It highlighted concerns that primary schools were not preparing pupils for puberty before it started, or teaching the correct names for parts of the body. "There has to be a sex and relationships education programme right from the start of primary school, with some lessons every year," says Emmerson.

One of the factors holding schools back is training. Science teachers may find it difficult to put biological facts in the context of children's everyday lives, while sex and relationships education teachers may not be up to speed on the medical facts. "If the teacher is not sharp about accurate sexual health facts, it opens the door to organisations who may promote their views on sexual health - for example abortion, mingled with incorrect medical information," warns Emmerson.

Young people's awareness of services and support is also an issue. According to research from the Exeter Schools Unit, more than half of 15-year-olds do not know whether there was a birth control centre for young people available locally. The Department of Health framework says it is important that under-16s who are sexually active have the confidence to attend sexual health services. Emmerson says schools and youth groups have an important role in familiarising pupils with the local sexual health services, suggesting mock or actual visits to a clinic where pupils can role play questions and answers.

Technology, as ever with young people, presents both a threat and an opportunity. The internet and other digital media can be a source of danger if children access unsuitable content or put themselves at risk. But organisations - including the government - are also using digital media to promote sexual health to young people. Stephen Bitti, head of sexual health programmes at research and consultancy group MBARC, says this is something that must be approached carefully. He points out that young people may not want to follow a campaign on Facebook, for example. "There are concerns around confidentiality, privacy issues - they don't want friends to see them 'liking' issues around sexual health," he says. However, phone apps can work well - MBARC recently supported two young people to develop an app that gives details of London-based sexual health services and allows young people to review and rate services.

If such an app was available nationwide, it might help young people monitor the availability and quality of sexual health services under the new commissioning system. But many feel something with more teeth is needed. "The sexual health framework is positive, but there is no mechanism by which it will be delivered," says Ingham. "The successful teenage pregnancy strategy had an obvious route through which messages could pass and best practice be disseminated with 150 teenage pregnancy co-ordinators, but they have nearly all disappeared."

Local directors of public health have plenty on their plate. It will be vital to make sure sexual health services do not fall by the wayside.

Sexual Health Week runs from 16 to 22 September 2013. Its main focus will be the "XES - We Can't Go Backwards" campaign, run jointly by Brook and FPA (www.wecantgobackwards.org.uk)

ENGAGING YOUNG PEOPLE THROUGH DIGITAL MEDIA

By Jennifer Reiter, sexual health projects co-ordinator at research consultancy MBARC

There is considerable mileage to be gained from using social and digital media to engage and inform young people about sexual health.

In 2012, NHS Coventry commissioned MBARC to run a consultation with local young people to determine their interest in using social media to learn about local sexual health campaigns and services. The majority of those surveyed said they would not follow a campaign on a social media site - even though 72 per cent were users of Facebook. However, a significant minority of 37 per cent did show an interest in following a sexual health campaign through a form of social media. What concerned the young people we consulted with was confidentiality, safeguarding and privacy. There are campaigns that engage successfully with young people through social media, including those run by the Terrence Higgins Trust, NSPCC and Save the Children. And further education colleges often put information about on-site and community sexual health services on their password-protected intranet for learners.

Last summer, the London Sexual Health Programme decided to mark the city's hosting of the 2012 Olympic Games by prioritising the sexual health needs of young people. The programme commissioned MBARC to work with young people under the theme of "engagement". We took on the exciting challenge of creating a competition called Sex Factor Ideas 2012, where young people submitted ideas for campaigns, condom designs and educational resources that would help their peers better manage their sexual health. Videos of their ideas were uploaded to YouTube and voters "liked" them to give them a chance at winning.

We also used other social media to promote the Sex Factor competition including Facebook, Twitter and a blog (http://sexfactorideas.wordpress.com) where winners could share progress on their ideas. The two gold winners are using social and digital media in thoughtful ways to engage with young people. Sexplanation, a sexual health display, is currently planning a pilot study in which mock-ups of their proposed art work and models will be displayed on tablets. Young people will be able to view the artwork from different angles on tablets and then immediately share their opinions about the proposed exhibit via an online survey.

Well Happy, a young people-focused Smartphone app that connects users to find and rate sexual, mental health, and drug and alcohol services in London, was created through a partnership between My Health London, MBARC and Living Well. The gold Sex Factor winner worked with a young staff member from My Health London to lead on guiding the development of the app. They ran focus groups with young people to decide on the look, usability and name of the app. The app is live and free to download.

SEX & YOUNG PEOPLE: STATS

The average age of first heterosexual intercourse is 16 years old

Approximately one in ten 16- to 19-year-old women with a sexual partner does not use contraception

In 2012, 23 per cent of 16- to 19-year-olds visited an NHS community contraceptive clinic

2011 saw the lowest rate of under-18 conceptions in the UK since 1969

Under-25s accounted for 64 per cent of all new chlamydia diagnoses in 2012

Young women in England are more at risk of contracting an STI than young men. For every 100,000 girls aged 15 or under, 53 have been diagnosed with chlamydia, as opposed to seven boys. For every 100,000 15- to 19-year-old females, 2,844 have a chlamydia diagnosis, compared with 960 young men.