Expert Adviser for NICE on the Commissioning of Sexual and Reproductive Health
Peter has 20 years of experience in the UK’s healthcare sphere. He has worked as a Joint Commissioning Lead at Royal Borough of Kingston upon Thames and NHS Kingston CCG. He has been responsible for commissioning tertiary care, ambulance services and primary acute care. Furthermore, he is a senior policy expert for the regulatory body ‘The Competition & Cooperation’ for NHS funded services.
He currently expert adviser for NICE on the commissioning of sexual and reproductive health, with responsibility over the CCG community service budget. He assisted in the development of guidelines for regulated fertility services, and created a set of tools to increase the take up of NICE recommendations.
Section 1: The Current State of Male Sexual & Reproductive Health
1.1. What are the biggest current issues in male sexual health?
I think the general messaging would be, that we’ve seen a rise in sexually transmitted infections. We’ve seen some specific exponential rises in summer infections, so there’s a significant rise in over 25s in chlamydia cases in this latest data that was only released in the last month, we’ve got some troubling rises in gonorrhea and syphilis. Which is where you get into subgroups there around men who have sex with men versus heterosexual men.
We’ve seen a rise in abortion requests during COVID, during lockdown, which would indicate a rise in unintended pregnancies, and obviously a man has a part to play in that, so there’s implications around men’s self-responsibilities for their reproductive health and of women’s reproduction.
Alongside those, we do have an increasing public discussion happening around men’s reproductive health, and I believe that can only be a good thing. There are some troubling aspects in terms of the rise of STIs. We know that men are not necessarily taking as much responsibility around reproductive health as they could, but we do see an ever increasing public discourse around men’s reproductive health, and I think that’s a good thing.
In 2013, a set of services we classed as public health left NHS responsibility, and became the responsibility of local government, and open access sexual health services, so that’s what we would call level three, the specialist consultant-lead service. Although it is often delivered by the NHS, it’s actually no longer the funding responsibility of the NHS, it sits with local government. So, that happened in the financial year 2013/14. In the financial years 2015/16, and each following year, up to and including, the 2019/20 financial year, there were year on year cuts to the public health budget, from central government.
What you’ve seen across the country is a mass rationalization of sexual health services. Now, some of that has been mitigated by things like digital solutions and London has, and what I would probably could claim as a world class online sexual health service, of which 29 of the 33 local authority areas in London are partners to. So you can be clinically assessed using a digital system. You can have a kit sent to your home, you take your own samples, you return them, health advice, and when we talk about help advisers in sexual health, these are not low grade support workers, these are qualified health advisers. You can get that through that system, and so that has shifted an awful lot of sexual health activity, which often sits predominantly with men, online.
And that is a right solution. It offers flexible access for people, they’re not pinned to certain times of the day, they’re not sitting in waiting rooms for three hours. So that’s a perfectly sound solution and is perhaps, sort of, an invention coming from necessity, as it were, that significant money had been taken out, but nevertheless, coincidental or not, we’ve seen year on year decreases in public health budgets until this financial year. And alongside that, we’re seeing an increase in abortions in women, we’re seeing an increase in STIs across the board, we’re seeing specific increases in some diseases and we’re seeing specific increases in some age groups.
1.2. What are your thoughts on specific disease groups?
We’ve seen specific spikes in chlamydia for the over 25s, and we’re seeing spikes in syphilis and gonorrhea, although, they are predominantly in our men who have sex with men. If I talk to, for example, chlamydia, in the 15 to 24 range, it has stayed broadly the same, as it were, over multiple years at an England level. If I talk to the 25 plus range, then we’ve seen proportionately the absolute numbers are smaller than in the under 25 group, but proportionately we’ve seen a fairly material rise, and that really has been pinned to the last two years, to 2018 and 2019 calendar years. So the STI data is reported in calendar years, so when I speak about prevalence and disease and things, I’m talking in calendar years, not financial years.
1.3. What is the impact of generic drugs on the male sexual health space?
In reproductive health, sexual health and HIV treatment care the impact of generics has been significant. It’s been an absolute benefit to the public purse. It has really offered opportunities to those, either choosing not to, or ineligible for NHS or state funded intervention. If we think about things like Viagra, obviously the biggest change in Viagra was two fold, it wasn’t just the generic availability, it was that it went off prescription only. We do know of a sizeable increase in usage of Viagra as a private prescription. Same to for PrEP, the HIV prevention treatment intervention. There’s been a three-year trial of that in England, which is just ending, and we’ve only just began to move to routine provision. Under the trial, there were only so many spaces available on the trial and there was a sort of research eligibility criteria to the trial. So we do know that a lot of people either couldn’t get onto the trial or weren’t a prime candidate to be recruited into the trial.
What we know is that as PrEP was emerging three years ago, the private cost of self-funding PrEP was quoted somewhere in the region of say, £400 a month. That has fallen by 90%, and we’re looking at people now who can self fund PrEP use at £30 to £40 a month.
There was a social media drive by the LGBT MSM community sector, that educated, primarily gay men, gay and bisexual men, on the different generic products that were available on the market, that had the same compound and the same levels of compound as the brand and directed and educated these men as to where they could get their hands on that so that they weren’t buying dodgy versions of the drug.
1.4. What are the biggest reproductive health challenges right now?
I think that there’s an ever increasing role on male fertility, as opposed to just reproductive health, beyond the use of Viagra and performance and STIs. There’s an increase in conversation on male fertility. I think that that is finessing into a conversation that says, whether or not a woman gets pregnant isn’t always down to the physiological health of the woman, and whilst we’ve maybe always known that, we seem to have succeeded in identifying key factors for women, and then we have a cohort of couples that get things like fertility intervention, treatment, assisted conception treatment, where we’ll describe the situation as an identified case of infertility, an unidentified cause.
I think really what’s happening is, we’re beginning to realize that we don’t know as much about men’s reproductive health as we believed we did, or that we should know, and we certainly don’t know enough about sperm and sperm modality and mortality, as we should know. I think there’s an ever increasing interest in learning more there, and I think that’s all the public level, I would point to this BBC documentary, which gained a lot of traction, with these two brothers, but also it’s a science and healthcare level. I think there is increased concentration on learning all we can about male reproductive health and male fertility.
Section 2: Treating Men’s Reproductive Health
2.1. What channels do men seek when seeking sexual/reproductive care?
The real difference between men and women and where they can seek that core care for sexual reproductive health, is that the majority of women come forwards in primary care around their reproductive health, and in general terms, primary care GPs are the backbone of our contraceptive reproductive health offered to women. So the vast majority of women are engaging with primary care, engaging with their family doctors on a very regular occasion throughout their lives. They’re engaging with them for contraception around their family planning, they’re engaging with them obviously around their pregnancy, but also not being able to get pregnant is the second most common reason why a woman visits her GP, after pregnancy itself. They’re, quite rightly, getting inordinate amounts of support and continuity of care from their GP. However, the offer around STI screening, STI consultation, testing and treatment in primary care is in very broad terms, next to zero.
We really don’t have a primary care based or a GP-based structure around STI testing and intervention. Not only does that mean that the women who are going around their contraceptive health, are not being offered at the same time screening around STIs, and remember, we have just said that the vast majority of women are getting their contraceptive health met in primary care, but it also means that men do not have that same relationship around their sexual reproductive health with their family doctor, as women do.
Men are not building up a life-course relationship with their family doctor around their sexual reproductive health, and most men who were coming forward, really around their sexual health, men, as we’ve already said, historically, don’t really think about their reproductive health very much. Men are getting their sexual health care met within these now local government commissioned specialist sexual health services. So what was once called GU medicine. They’re brilliant services, they’re specialist consultant-led services, they’re expensive services, and they offer a great service.
They’re open access, so you can go wherever you are in the country, you don’t need to be registered with a GP locally. Many are open into the evenings and weekends. I think it is unfortunate that men do not have the opportunity to build a similar relationship with their family doctor about their lifelong sexual and reproductive health as women do. Don’t get me wrong, the loss is for women as well, because I suspect there are a lot of women having their reproductive health care very well taken care of, but not necessarily their wider sexual health care.
2.2. How many men are infertile? How do we manage male infertility?
The number of couples coming forward for some form of intervention around their inability to gain a pregnancy, to achieve a pregnancy, is higher than 9% to 12%. So that either indicates that the larger proportion of issue is with women, which it may well be, physiologically, or it indicates that we have either underestimated, or we don’t know enough yet, about men’s aspects of reproductive fertility and reproductive health.
If we want to strip it back to the absolute public health basics, as young adults and to a degree as children, and then as young adults, we have for many years concentrated on educating people on how to protect themselves from STIs, and not to get pregnant. Whether or not it’s had the best outcomes, that is what sexual health education, relationship and sexual health education, RSE, concentrates on. From this year, give or take a year, the intention is it becomes a legal obligation.
We’ve had a requirement around PHSE for a very long time in schools, it’s a mandated element of the curriculum, but the last time we’d had any national strategy or policy on relationship and sex education in schools was a long time ago, and we’ve waited until now, 2019 into 2020, for further action on that. The government has made a legal element of the education bill around relationship and sex education. The temptation again will be that it will concentrate on not getting pregnant and not getting an STI. And whilst that is understandable, what it means is, we send young people out into the world, knowing how not to get pregnant, but with absolutely no education around what to do when they want to get pregnant, and around what they need to think about when they want to get pregnant.
It’s easier to relate it to women, if we think about that from a female perspective, we quite rightly tell women, you can be whoever you want to be, you can achieve whatever you want from this world, but we don’t educate them that if you want to achieve a pregnancy, your fertility falls off a cliff at the age of 35. So, you quite rightly go ahead, you champion your career, and then at 38 you decide, you’d like to have children, but you can’t get pregnant as easily as you thought, but we don’t educate people to that fact.
Whilst men are not quite affected in the same way, we do know that there is an age issue with fertility for men, but we certainly know there’s an age issue with modality and mortality in sperm. We know that there are other aspects that can determine quantity and quality of sperm, but men wouldn’t think to consider that until they’ve been trying with their partner to get pregnant for two years and it’s never worked, and then the doctors intervene. For example, we tell men to check their balls around cancer, but we don’t educate men to check their balls with a mind to their fertility, so for example, size determines quantity of sperm that is made. Yes, I think that if we want to view it as a public health piece I think we need a rounder relationship and sex education process that educates young people, also to what fertility is, and not just what reproductive health is.