IPR Blog

Expert analysis, debates and comments on topical policy-relevant issues

Topic: health

Do Warnings Work?

📥  health, Risk

Professor Bill Durodié is Professor and Chair of International Relations in the University of Bath's Department of Politics, Languages and International Studies. The narrative presented here was supported by an award from the Gerda Henkel Stiftung under their Special Programme 'Security, Society and the State'.

It is commonly asserted that the first duty of government is to protect its citizens. But one of the challenges confronting authorities that produce advice and issue alerts is the extent to which precautionary messages have become an integral part of our cultural landscape in recent times. From public health to counter-terrorism, climate change to child safety, a profusion of agencies – both official and unofficial – are constantly seeking to raise our awareness and modify our behaviour whether we know it or not. This may be done with the best of intentions – but we should be mindful of where that may lead.

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Issuing a warning presumes negative outcomes if it is not heeded. Accordingly, it transfers a degree of responsibility to recipients who may not have sought such counsel – or been consulted. Indeed, these may come to interpret it as a mechanism to deflect blame and accountability. And, aside from the intended response – presumed appropriate by those imparting the information – others may dispute the evidence presented, its interpretation, and the intentions behind these, as evidenced by acts of complacency and defiance.

Such negative consequences – deemed maladaptive by politicians and officials who have swallowed the psychologised lexicon of our times – reveal an important truth in our supposedly post-truth societies, and that is that people are not driven by evidence alone. Addressing their core values and beliefs is more critical to motivating change and achieving influence. This requires respecting their moral independence and recognising the importance of ideas. Process and data-driven, protectionist paternalism, on the other hand, reflects a low view of human beings, which is readily self-defeating.

Altering our choice architecture, as some describe it, encourages self-fulfilling prophecies that interfere with our autonomy and undermine consent in the name of improving welfare or keeping us safe. And while there is a wealth of literature regarding such interventions and their purported effectiveness, most relates to single cases or relies largely on precedent – such as preparing for terror attacks or controlling tobacco use – rather than examining the implicit assumptions and the wider, societal consequences of such approaches.

Responses like overreaction, habituation and fatigue derive not so much from specific instances of warning as from the cumulative impact of a cultural proclivity to issue such guidance. This latter, in its turn, speaks to the growing disconnect between those providing advice – even if at arm’s length from the state (thereby inducing a limited sense of civic engagement) – and those charged with living by it. To a self-consciously isolated political class, proffering instructions and regulating behaviour appears to offer direction and legitimacy in an age bereft of their having any broader social vision.

Yet, reflecting on the UK Foreign and Commonwealth Office provision of travel advisories before and after the 2002 Bali bombings, the distinguished Professor of War Studies Lawrence Freedman noted how such guidance ‘is bound to be incomplete and uncertain’. ‘[I]t is unclear’, he continued, ‘what can be achieved through general exhortations’. Far more important to averting accusations of complacency or alarmism on the part of government – ‘the sins of omission and commission’, as he put it – is the need to impart and share in a sense of strategic framing with the public. We might call this politics.

In his 2002 speech at the Lord Mayor’s Banquet, the then British Prime Minister, Tony Blair, advised how intelligence on possible security threats crossed his desk ‘all the time’. Only some was reliable. The remainder included misinformation and gossip. He sought to distinguish between specific intelligence, suggestive intelligence and acting ‘on the basis of a general warning’, which would effectively ‘be doing [the terrorists’] job for them’.

Blair explained how there was a balance to be struck and a judgement to be made ‘day by day, week by week’ in order not to shut down society. He noted that keeping citizens alert, vigilant and cooperative would test ‘not just our ability to fight, but … our belief in our own way of life’. In doing so, he implicitly pointed to the need for wider critical engagement and our having a sense of collective purpose beyond the immediacy of any threat.

But nudging people to act without their conscious support and endlessly raising awareness about all manner of presumed risks and adverse behaviours precludes both of these essential elements. Indeed, when some suggest that the general population are inherently ignorant, not qualified or too immature, or that they cannot be relied on to handle complex evidence to determine matters for their own good (an argument as old as Plato), they display a considerable complacency of their own, as well as an unwillingness to engage and inability to inspire a broader constituency to affect change.

People can only become more knowledgeable, mature and reliable when they participate actively in matters of consequence. There can be no shared sense of social purpose if citizens are not treated as adults. Otherwise, official pronouncements come across as the disengaged exhortations of remote authorities, and warnings – as with the increasingly graphic images on cigarette packets – simply become the background noise of the self-righteous.

The refusal to be inoculated against H1N1 pandemic influenza once a vaccine was developed for it in 2009, for example, did not stem from social media propagation of ‘rumours’ and ‘speculation’ on ‘volatile’ public opinion as some supposed. Rather, and more damagingly still, it was a conscious rejection led by healthcare workers themselves, informed by their own experience of the virus, and inured to the declarations of senior officials who announced that ‘it really is all of humanity that is under threat’, as well as those who responded uncritically in accordance, developing models where none applied.

The language of warnings has shifted over the years from articulating threats, which could promote individual responsibility, to simply eliciting desired behaviours. Indeed, the proliferation of biological metaphors – ideas go viral, individuals are vulnerable, activities are addictive – reflects the demise of any wider moral or political outlook. But encouraging a responsive sensitivity and tacit acceptance by evoking negative emotions can readily backfire. It is unlikely to generate a critical culture or social solidarity.

So – do warnings work? It depends. Facts alone do not motivate many. It is how they are interpreted that matters. And the framing of these today often dismisses our agency and promotes a powerful sense of determinism. The Nobel Prize winning economist Daniel Kahnemann noted how ‘[t]here are domains in which expertise is not possible’. Decision-making – like democracy – is a moral choice in which we are all equals.

Not everything of value has a value and few things that are worthy have a worth. That is why the sole pursuit of evidence and data by those in authority, with a view to inducing acceptance and behaviour change, fails to inspire those who seek more to life than the mere protection of the state. Where are the ideas and ideals capable of leading us beyond a narrow, existential concern for our own well-being and towards a broader appreciation of the potential of the collective human project?

This piece also appeared on The Policy Space.

 

Is reform of social care doomed?

  

📥  health, Political sociology, Public sector

For people who have worked in UK public policy in recent decades, whether as civil servants, politicians or advisers, there is something wearily familiar, and depressing, about the current debate on the reform of social care. A fair chunk of the period I worked in No10 Downing Street, between 2007 and 2010, was spent on social care policy: on reports commissioned from the Prime Minister’s Strategy Unit, papers drafted by committees of civil servants working up options for cabinet sub-committees, notes for political discussions between ministers, party conference announcements, and even legislation. None of it went anywhere. Cross-party talks were scuppered by the Conservatives, the Treasury dug in against reforms considered fiscally unsustainable, and Labour malcontents in the House of Lords blocked legislation that they thought was partial and incoherent. Nor did it get much better after 2010 – Andrew Dilnot was commissioned to review social care funding, but his recommendations were kicked into the long grass, while local government spending on care services fell under the heaviest of axes.

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Why has social care remained unreformed, when other public services have been subject to extensive, often unrelenting change? It is not simply lack of political will, though that has played a part. Nor can it be that the funding and organisation of social care is more complex and difficult to reform than other areas of public policy; pensions’ policy, for example, has been successfully reformed, on a largely consensual basis, in the last decade. The concepts of mainstream public policy analysis – punctuated equilibria, multiple streams analysis, or narrative policy frameworks through which policymakers make sense of the world – do not seem to provide much explanatory help. Instead, we should look to the political economy of welfare states.

The social care system (here taken to refer primarily to social care in England) is staffed by low-wage, largely non-unionised, predominately female employees working for private companies. There are no high-status, powerful professionals, like NHS hospital consultants, in social care – nor strong trade unions organising a high proportion of care staff. The workforce is heavily dependent on EU migrant labour. Services are mostly commissioned from private companies by local government, rather than provided by the public sector itself. Social care was kept separate from healthcare in the 1948 settlement, meaning that it has never benefited from the popular support and protective institutional aura of the NHS. Social care consequently does not generate institutional interests that are capable of powerful political expression: the labour voice is weak; professional vested interests are marginal; there is no national public sector body responsible for the service; and the business interest is uncoordinated.

Older people using social care are not politically mobilised, like parents of school children or NHS patients. Most of us are myopic about our future care needs; we tend not to plan ahead for the care we will need. For those suffering long-term conditions, like dementia, care will be needed for a long time – but for many of us, care services will be limited to end-of-life support of relatively limited duration. We know that we will need a pension for retirement, and health services throughout our lives, but not whether we will require social care. This means that the state is under limited pressure properly to fund and improve care services. In recent months, much of the political concern about social care has been generated by the knock-on impact that cuts to local government services have had on the NHS.

The social care systems of so-called liberal welfare states like the UK, Ireland, Australia and the USA, share many features. They are residual, relying heavily on limited means-tested safety nets, rather than providing universal coverage. Low levels of expenditure on means-tested assistance are funded from general taxation. At the same time, private care insurance is limited (non-existent in the UK case), but nor is there comprehensive social insurance or a compulsory care saving, as is typical of countries like Germany, France, Japan and Korea. Social care systems therefore tend to typify the welfare states of which they are a part: individualised, means-tested and general-taxation-funded liberal systems; universal, tax-funded Nordic systems in which care needs are decommodified; continental care systems that have developed from tripartite-funded (employer, employee and the state) social insurance systems; and East Asian systems in developed economies that have expanded compulsory care insurance coverage as their populations have aged, based on co-funded mechanisms.

Social care has also tended not to feature in Social Investment State (SIS) strategies that have dominated welfare state reform discourses in the UK and elsewhere since the 1990s. SIS conceptual frameworks prioritise employment and human capital investment, and privilege childcare and support for parental employment, over care of the elderly and adults with disabilities.

What then are the prospects for successful reform of social care in this latest round of policy debate? Substantively, the UK is unlikely to pursue the compulsory/social insurance or universal tax-funded reform options that have been developed in other welfare states – we lack the political economic foundations and politically mobilised social group interests for those kinds of reforms. More likely, ministers will tilt towards co-payment models or tax-incentivised private savings vehicles, with a floor of means-tested support. These will be partial and inegalitarian, however, since they do not pool risk across the population, and they tend to squeeze those who have income and assets just above the threshold for means-tests, while enabling those higher up the income and wealth distribution to buy better services, and forcing low-income families to rely on low-quality services – poor services for poor people. Meanwhile, ministers will put just enough funding into social care services to stave off collateral damage to the NHS, as the Chancellor did with an extra £2 billion over three years in his budget.

Pressure for change may depend on the politics of ageing. Turnout in UK elections is heavily skewed towards older voters, who currently form a solid bloc of support for the Conservative government. This demographic political inequality is commonly thought to explain why pensions and benefits for older people have received relative protection in the era of austerity, while inheritance tax is cut and wealth levies (the so-called "death tax") are abjured. Academic research into the politics of age is unfortunately more limited than that into social class or occupational groups (although it is a growing field and interest from think-tanks has been developing). The politics of social care may come to turn on whether the collective interests of older people and their families in the provision of properly-funded, comprehensive services, integrated with the NHS, can trump both the social class differences between them and the lack of broad coalitions of support that currently inhibit progressive social care reforms. For now, Whitehall watchers will not be holding their breath.

 

Shifting the public conversation on mental health – understanding the social conditions that shape private troubles

📥  health, policymaking

Professor Simone Fullagar is Professor of Sport and Physical Cultural Studies in the University of Bath's Department for Health

Mental health professionals, NGOs and a variety of service-user groups have all called for greater funding for local and global mental health services, as well as for greater parity of esteem between these services and broader health policy and service provision in the UK. The Mental Health Taskforce’s 2016 report details the need to address chronic under-spending on mental health services in the UK as demand continues to increase and inequalities widen. NHS spending is increasing in areas that support a medicalised response to mental health issues, with prescriptions for antidepressant medication doubling over the last decade in the UK. The taskforce’s report recommends a billion-pound investment in 2020/21 and calls for fresh thinking to shift cultural attitudes that stigmatise mental ill health as an individualised problem. Recently Theresa May announced a review of child and adolescent services in England and Wales and investment in mental health first aid training for schools. This is an important step, but how far will it go, given that from 2010 to 2015 there was a reduction of 5.4% in the funding of child and adolescent mental health services in the UK?

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Young people are a major focus of concern, as they suffer from high rates of depression, anxiety, eating disorders and are vulnerable to developing more severe and enduring conditions. National survey data indicates a worsening picture for young women (15-18), who have the highest rates of depression and anxiety in the UK. Suicide rates have increased, with young men experiencing higher rates of suicide than young women, who in turn have higher rates of hospital admission for self-harm. One in four (26%) women aged 16 to 24 identify as having anxiety, depression, panic disorder, phobia or obsessive compulsive disorder.

The case for greater funding for mental health services is supported by a growing body of evidence which points to the value of investing in appropriate support and early intervention. Recent psychological research in the UK identified how different therapeutic approaches (cognitive behavioural therapy (CBT) and psychosocial interventions) for adolescent depression have been found to have similar beneficial effects. Across different approaches there is a common thread emphasising the importance of developing a ‘therapeutic alliance’ with a young person so they are able to effectively engage with support (feeling heard and respected, avoiding further stigmatisation, being involved in coproducing services, etc). This question of what works best for young people with a range of needs and diverse social backgrounds is an important one, given the role of the Improving Access to Psychological Therapies programme in increasing access to psychological therapy via CBT as a technical formula. Research has identified that 40–60% of young people who start psychological treatment also drop out against advice. A high proportion of people also do not seek help from professionals despite the recurrence of common mental health issues. All these factors point to the complexities surrounding clinical and community-based mental health provision. A positive shift in recent years has been an increasing recognition of the importance of involving people with lived experiences in the coproduction of localised services that move beyond privileging biomedical treatments, and support a recovery-oriented approach (for example, the Wellbeing College for adults has been created in Bath).

While this focus on funding more personalised support is incredibly important for people experiencing all kinds of distress, we also need broader public conversations and policy approaches that offer a critical understanding of how private troubles connect with our public lives to acknowledge the social determinants of mental health. Mental health problems are associated with social injustice, marginalisation and the embodied distress of trauma – poverty, discrimination (class, gender, sexuality, ethnicity etc), poor housing, unemployment, social isolation, gender-based violence, childhood abuse and intensified bullying in the digital age. In the context of austerity measures and cuts to public funding across a range of areas, it is perhaps not surprising that private troubles and social suffering are exacerbated.

Mental health and illness are also highly contested concepts with diverse, and often competing, trajectories of thought about biopsychosocial causes and conceptualisations of distress. Public knowledge of ‘mental illness’ is historically shaped by our diagnostic cultures of psy-expertise (from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to digital self-assessments), the rise of brain science and research funded by Big Pharma, and the less-often-heard accounts of those with lived experiences (including a diverse range of identities – service users, consumers, and members of anti-psychiatry, hearing voices and mad pride movements). While there is often great media interest in studies claiming to identify the biological cause of problems in the brain (often visualised via high tech images), many people would be surprised to know that there are no specific biomarkers for ‘mental illness’ – and theories about why anti-depressant medication works for some people (and with similar effects to placebo and other non-pharmacological treatments), are based on hypothesis rather than fact.

If we look at the national data cited earlier we can see how gender figures as an important variable – yet there is a curious absence of gender analysis in the context of mental health policy and service provision despite the growing research in this area.  My own sociological research into women’s experiences of depression and recovery identified the often highly problematic effects of antidepressant medication that was prescribed to help them recover. Women spoke of how their embodied distress was heightened by side-effects, and how feelings of emotional numbness exacerbated their sense of ‘failing’ to recover despite following expert biomedical advice. Suicidal thoughts and attempts were evident alongside guilt about not living up to the normative ‘good woman ideals’ of self-sacrificing mother, productive worker or caring wife. Others identified a feeling of being paradoxically trapped in a sense of dependency on a drug that helped them to feel more ‘normal’ and thus able to manage the gendered inequalities and pressures of their lives with demanding caring roles, work or unemployment. Restrictive gender norms, experiences of inequality that intersect with class, ethnicity, religion, sexuality and age, as well as a lack of gender-sensitive provision within mental health services and beyond (childcare, housing, domestic violence support, access to low-cost community activities that support well-being) were key policy related issues. The policy challenge ahead of us is to understand the complexity of how mental health is affected by, and affects, all aspects of social life. Social science research has a unique contribution to making critical issues (such as gender inequalities) visible in the development of a whole range of approaches, decision-making processes about resources and public dialogue about how we understand the social conditions that shape distress and support wellbeing in the contemporary era.

 

How do we decide what works in wellbeing?

📥  data science, health, Uncategorised

Emily Rempel is an interdisciplinary PhD student in the Department of Psychology and the Institute for Policy Research at the University of Bath.

The region around the University of Bath is a relatively ‘well’ local authority. By this I mean that Bath and North East Somerset (B&NES) consistently ranks at or above average on the ONS measures for wellbeing, which include population scales of life satisfaction, anxiety, worthwhileness and happiness. B&NES, and other surrounding authorities, are committed to providing services that address these kinds of measures and seek to increase the wellbeing of the people that use their services. Examples include the Wellbeing College, Developing Health & Independence and Second Step Housing Association. While one can assume there is significant worth in increasing the wellbeing of a community for that community’s own cohesion and happiness, there are also more economically minded ideals behind the push for wellbeing. The main driving concept is that happier, more stable people are healthier people and that healthier people use public services less and ultimately save money for institutions like the NHS. This sounds all well and good: people are happier, governments are spending less money and we all end up better off. But the reality is far more complex. That basic assumption that happiness leads to cost savings requires, for lack of a better word, evidence.

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What constitutes evidence in wellbeing is both politically and practically challenging. An essential first question is: what do we mean by wellbeing? Professor Sarah White, Professor of International Development and Wellbeing at the University of Bath, has written extensively on this issue. She argues that wellbeing includes a variety of factors from subjective assessments of happiness to objective ‘quality of life’ measures1. Professor White also describes key differences between individual concepts of wellbeing and collective wellbeing – personal happiness versus national economic health, for example. While there is no easy answer to the question of what wellbeing consists of, local and national governments have provided several frameworks in order to measure wellbeing (and provide services that address it). The aforementioned ONS scales are one example of measuring and defining wellbeing at the national level. Another commonly used framework is the New Economics Foundation’s commissioned work on the Five Ways to Wellbeing. This distils subjective wellbeing into five key areas: be active, take notice, connect, giving and keep learning. Although they consist of a frustrating mix of participles and infinitives, the ‘Five Ways’ are often used by both third sector organisations and local authorities to conceptualise wellbeing. However, none of these definitions offer a holistic and comprehensive concept of wellbeing. To add a bit more complexity, when it is difficult to define it is also difficult to measure – how, for example, do we measure the Five Ways? And more specifically, how do we measure whether programmes like those listed above address these areas? What constitutes success?

From my own experience, measures of wellbeing are at least as complicated as definitions. Assessments of local wellbeing services often contain a battery of different kinds of measures. Much of this diversity is due to diversely vested interests in what these wellbeing services do. Is the purpose of the service to address personal wellbeing, save money or improve health? Or all three?  From a subjective wellbeing perspective, measures like the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) are appropriate. However, this does not capture economic wellbeing or objective measures of personal environment. For example, knowing that someone has a score of 56 out of 70 on the WEMWBS tells us nothing about whether they live in a stable and safe home environment. From the health and economic perspective, administrative data is often used to see if individuals who participated in wellbeing courses or activities used health services less. But can we be sure that a decrease in health services use is not due to other factors? There are seasonal, regional and personal variations in health services use that are difficult to capture with administrative data. Furthermore, how can we be sure that using health services less indicates people are healthier? From an individualistic perspective, the Five Ways to Wellbeing could be measured simply by asking people how they ‘connect’ or how much they ‘connect’ in their day-to-day lives. But does every individual interpret ‘connecting’ in the same way? As always, it is difficult to create consistency in subjective, individualistic measures. More broadly, how can we expect a wellbeing service to show success on all of these different kinds of measures? When there is a lack of conceptual clarity, muddles in measurement will follow. The solution is not to throw everything at the wall and hope that something will stick in the name of evidence. There needs to be a better understanding of what these services and activities offer if ‘wellbeing’ is to be addressed in the community.

It would be logical to assume that the solution to this lack of evidence in wellbeing services is simply more evidence. However, as outlined above, the answer is not so simple. Instead of more evidence, there must be a shift towards the right kind of evidence on whether services improve individual, and therefore community, health and wellbeing. First, there must be a critical review around the causative assumptions of wellbeing activities. This means picking apart the impact a typing course has on wellbeing versus a yoga class. Each has value, but measuring them the same way would be a misstep. This means taking a step back from the assumption that improved subjective wellbeing leads to, and necessitates, cost savings. For example, administrative health records are unlikely to tell us if a basket weaving course is effective. Furthermore, basket weaving is unlikely to put the NHS in the black. It may be more effective to evaluate the impact of basket weaving via measures of social isolation. We need to unpick and critique the aspects of wellbeing that individual activities and courses address, and then apply the appropriate metrics to assess whether wellbeing improves. After those steps are achieved, there may be an opportunity to truly test if that personal wellbeing leads to improved health leads to cost savings causative narrative persists. In the end, measuring and commissioning wellbeing services is a national initiative that will continue whether we agree on what wellbeing means or not. And commissioners will likely project onto wellbeing services the kinds of changes they want to see in health services in general – specifically, less money, fewer patients and better population health. It is impossible to predict where this push for wellbeing will take us, but – as with any change in community health and public services – we need to be critical of how ‘well’ we really are doing.

1 White, Sarah (2014). Wellbeing and Quality of Life Assessment: A Practical Guide, Rugby, UK: Practical Action Publishing.

 

Cost over quality: sexual health in an age of austerity

📥  Economy, health, policymaking, Public sector

Dr Frances Amery is Lecturer in British Politics at the University of Bath and Co-Convener of the PSA Women and Politics Specialist Group.

Sexual and reproductive health (SRH) is a hugely important yet neglected area of public health. From access to abortion and contraception to treatment for HIV, SRH services are an essential part of efforts to address inequality. Yet SRH provision has been severely impacted by the NHS restructure precipitated by the 2012 Health and Social Care Act and by subsequent cuts to public spending.

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The policy background

Department of Health guidance on SRH provision is set out in A Framework for Sexual Health Improvement in England, published in 2013. The Framework was published amid widespread uncertainty about what the upcoming reforms to the NHS would mean for SRH services and calls for the government to clarify its approach, while responding to evidence of inequalities in the sector. In particular, campaigners and medical organisations called for a life course approach to SRH which takes into account the ways in which men and women’s needs change with age.

The Framework appears to address these concerns. Equalities issues are foregrounded throughout: the document draws attention to the need to tackle discrimination and stigma surrounding sexual health matters, to ensure equality of access to services, to promote good body image and self-esteem, and to raise awareness of issues surrounding consent. Throughout, the different needs of different social groups and identities are highlighted. Calls for a life course approach are also addressed in a section titled ‘Sexual health across the life course’.

On paper, there has been a clear attempt to respond to demands of various advocacy groups. But as many equality policy researchers have observed, good intentions on paper often do not result in equality in practice. Indeed, the Framework has come under fire from SRH providers and campaigners for putting forward ‘ambitions’ without setting in place strategies to achieve them.

Inequalities remain in sexual and reproductive health

In spite of the high-flown ambitions found in DH guidance, huge inequalities in service provision and access remain. A 2012 report by the All-Party Parliamentary Group on Sexual and Reproductive Health (APPGSRH) found evidence of some local authorities barring women over the age of 25 from accessing contraceptive services, and sexual health charities suggest that this situation has not improved. There are also regional variations in the coverage of abortion services, with Scottish women facing significant barriers in access, while abortion law in Northern Ireland remains incredibly strict. Many women are not able to access abortion and contraceptive services under one roof, meaning that the quality of the care they receive is compromised.

Meanwhile, clinics around the country face the threat of closure due to budget cuts. An example is the proposed closure of the genitourinary medicine clinic at Whipps Cross Hospital, which campaigners say will have a disproportionate impact on black and Asian men living with HIV. While closed clinics usually have their services integrated into a larger clinic at a different site – as is planned for the Whipps Cross clinic – there is often still a negative impact on the community as patients lose access to local services. Some patients may not be willing or able to travel the longer distances now required of them.

Particular difficulties exist regarding trans people’s access to services. Demand for trans services is booming, yet there are only a handful of gender identity clinics in the UK. Waiting times are astronomical, with some clinics predicting that new patients will have to wait four years for their first appointment.

Among all this, race is a cross-cutting issue. Black, Asian and minority ethnic (BAME) communities tend to suffer worse health outcomes than the general population, and sexual health is no exception: BAME communities bear a disproportionate burden of HIV, and BAME people can sometimes face more stigma and greater barriers when accessing sexual health services. This problem is worsened by the closure of clinics servicing local communities. There is also a lack of representation in service provision: for example, BAME trans people might never meet another trans person who shares their background when attending treatment and support groups.

Why aren’t we delivering adequate services?

The government’s ‘ambitions’ regarding SRH provision and related inequalities are hindered, in large part, by fragmentation in commissioning and service provision. Lack of centralised, top-down direction is not necessarily a problem for healthcare, and local networks can be key players in advancing healthcare services. But in this case, fragmentation has been accompanied by a lack of accountability within commissioning structures resulting in gaps in service provision. This was already the case before the Health and Social Care Act 2012 came into force, but has been worsened by the subsequent restructuring of the NHS.

The Health and Social Care Act abolished the existing structures responsible for commissioning services and replaced these with new Clinical Commissioning Groups (CCGs), as well as establishing new national bodies. Responsibility for commissioning the various services making up sexual and reproductive healthcare – including abortion services and HIV treatment – is now spread out among CCGs, local authorities and the national commissioning board, although the lion’s share of responsibility rests with local authorities. The APPGSRH argues that this has resulted in a further loss of clear lines of accountability, which means that commissioners are not able to work together effectively. These commissioning silos can mean that it is not possible to deliver integrated services under one roof, since abortion and contraceptive services, for example, are commissioned by different bodies. Public Health England, the new executive agency with responsibility for SRH (among other aspects of public health in England), has ‘reducing health inequalities’ as a key part of its stated mission, but little role in policy formulation. Initial claims that the body would ‘speak truth to power’ appear to have been forgotten, and it has so far shown an unwillingness to challenge government policy.

This has all been compounded by the politics of austerity and in particular by cuts to local government budgets. Since November 2015, local authorities’ public health budgets have been separated from the budget for NHS England. This means that they are not protected from the latter’s budget ring-fencing, and public health spending has dramatically fallen as a result. While local authorities receive their own ring-fenced grants for public health, there is evidence that these are being diverted towards threatened services in other areas. Austerity has promoted unequal health outcomes directly, as clinics and services close or relocate as a result of budget cuts. Some contracting models appear to prioritise cost efficiency over quality, further compromising the services on offer.

Cuts to SRH services are a false economy – they result in drastically increased spending due to unintended pregnancies and STI infections. We should be more concerned, however, with the adverse impact of cuts on disadvantaged communities. While Theresa May has expressed an interest in social justice, it remains to be seen whether she will address the trends set in motion under her predecessor.