Martin Daly: Why Ireland Needs Public Sexual Health Clinics

First I'd like to thank all the witnesses for coming here today and it's a really important area and I have to agree with the Cahirleach that it is something that possibly, as I can see from your presentations, we've made a lot of improvements in terms of access, in terms of the recognition of the problems around sexual health and I was delighted with your presentation as well, it was very broad in terms of the interpretation. I think initially when I got some of the correspondence it seemed to be very narrow but as I sifted through it I think the presentation that we need to look at in a really global way and not allow it to be pigeonholed down into one group or one virus or anything else, so it's really, really important. So just moving on, maybe to expand on what you had said around your view and your organisation's view in relation to that global view of sexual health and I suppose the idea that there would be community sexual health clinics and I think Ireland probably, it's probably timely, I think it would be acceptable now, it mightn't have been acceptable 15, 20 years ago. I think it's a model that's used in the UK, so across London and the UK within particular local authority areas there would be a local sexual health service and it's not something that's unusual to us either because the IFPA, they have a pretty full service. So I think the issue is that it's around making those level of community based services much more accessible and much more available. So it stops people from having to go to, say they come to us for one thing and then they have to go to the local gun clinic for somewhere else and then they have to go somewhere else and it can be quite exhausting. And I think what's really important is a lot of sexual health issues are very, very time sensitive so I think by dealing with something within the one broad based community setting I think you've got much more equity of service delivery and I also think that you're addressing multiple needs of the community and you're normalising sexual health. Sexual health isn't something that should be hidden away, this is part of your everyday life, it's part of you as a human person. So it's trying to normalise that and encourage people really to look after and take care of their sexual health in the same way that they would any other aspect or element of their health. And I suppose again addressing your group and again maybe the HSE and the other witnesses as well, I mean I come from a general practice background and we would have always looked at my generation looking for additional information and services within a general practice setting but we also need to recognise capacity issues now and I think that's recognised here as well and I don't think that says anything against the training of a general practitioner, you may well have general practitioners working in your community clinic but it's about increasing access isn't it? And it's about the broad range of services, it's not just about sexually transmitted diseases, it's got to be much broader and I see from the HSE's presentation you have the clinic in Hatesbury Street for sex workers but also again coming back to that broader view, like sexual dysfunction, infertility, even those primary services that should be in the community and not just be the purview of the hospital system. Could I ask you to comment? I think it's more conversation, we'd better get more out of it. I think I completely agree with you and I think that I mean aspiring to what Sláintecha wants to deliver about the right care in the right place at the right time and that's how our model of care is being developed. We have a network of community based public sexual health clinics, I think they need to be empowered and resourced to work in an integrated way such that people can have the supports from organisations such as yours when they need it and also up to more complicated care when they need it but also that people, like the free contraception scheme, the launch of the free contraception scheme is something that has been very much welcomed in Ireland. In my practice I would see that there are people who aren't able to access the free contraception scheme when they come in to see me in clinic when they've got some other matter related to their sexual health. I think we need to overcome these barriers and improve access to contraception services within our sexual health, our network of public sexual health clinics such that they do genuinely become a single site at which people can access and have all of their sexual health care needs addressed. I hope that before I retire that we will start to talk about sexual pleasure and that we will address the huge unmet need there is in respect of sexual dysfunction. I think it's a testament to the chairperson today that he's been chosen by the committee to bring sexual health in here today because we need to have this conversation. Sex, we're here because of sex and it's really welcome that there are lots of things we need to do and I think that we need to, as you say, the focus is not just on STIs, it's not about sexual health, ill health, it's about people attaining sexual good health and actually maintaining and ultimately achieving pleasurable sexual health and addressing things like sexual dysfunction are a huge part of that and having their contraception needs met within the community services and certainly within our model of care that we're developing at the moment our clinical advisory group has agreed with this approach that people should have the things that they need as much as possible in one place. So we have plenty of work to do to get that completed but we will be completing it before the end of the summer. But it also removes the stigma of someone going to, say, for a gum clinic. You know, let's be honest, there are patients of mine who would say when I send them to the gum clinic, I'm not going to see anyone there, will I be waiting? I have to say gum clinics are set up to do that, I'm not making a judgement on that but I have to reassure them that that will be the case, that they will be looked after and that's why broadening it out away from just sexually transmitted diseases to sexual health in its global sense makes much more sense. And in that regard, that is why we very intently change the name to Public Sexual Health Services rather than STI clinics. I look after people in their 80s, 70s, who haven't had sex for many years, some who do still continue to have sex and want to have good sex and they don't have STIs necessarily and it's much more about the broader aspects of sexual health. So we very intently in the model of care have called our network of public clinics the Public Sexual Health Clinics, not STI clinics. And it should be about access but also about blended services right across the number. It's not the purview of any one given. But one of the difficulties we have is there's been a lot of lip service paid to primary services in primary care, which is where this should be. And we're not seeing the commensurate investment, and this is just another example, in primary care in relation to services. When we look at the disproportionate investment in the hospital sector, and we'll come back to say PrEP and PEP in a moment, there seems to be, any time there's a new idea, a restricted view on how access should be, certainly in relation to PrEP. And in PEP you were describing, I was reading in your statement, that it requires access to a hospital service. Maybe I'm wrong. Do you want me to speak to PEP first? Sure, and I'd be happy to hear from the other witnesses as well. So, as I mentioned, the GBMSM Sexual Health Working Group, when we, about two years ago now, we identified, we said we're going to look at our action plans, like let's pick three things to work on, and two of those priorities were doxy PEP guidelines, which are now done, and also improving access of PEP. So PEP is available through our network of sexual health clinics, public sexual health clinics, through our status for people who have experienced sexual violence when appropriate, and also out of hours through emergency departments. And it is a time-sensitive intervention, as Fiona has indicated, but the people may not have an actual medical emergency requiring emergency department attendance. So we've looked at multiple different ways, we've explored multiple different ways, and within our current legislative framework, what we can do right now is develop an online assessment pathway which overcomes the mandated emergency department attendance fees such that people can, through the home STI testing service, have an assessment done. If they meet the threshold for needing PEP, we've given a referral letter which overcomes a mandated fee which has been cited by the community as a significant barrier to accessing PEP in a time-sensitive way and actually was putting people off getting it or going to the emergency department. And then we also hope that in addition to improving access through overcoming that fee, that it will also reduce unnecessary attendances to the emergency department because there may be individuals who are concerned that they may need PEP, but following assessment, they may not actually need PEP and then therefore not need to go to the emergency department. Ultimately, what I would like to see is that it is available much more broadly, but current legislation, it's difficult within the current legislative framework to do that. I can go on to the PEP piece if that's OK? Please, yeah. Just in respect of restricted access, so it may seem restricted access, but from the very beginning, when we were establishing the PEP programme in 2019 and getting ready, I think it took us several years to get it ready, one of the key things we did at the beginning was ensure that it was available through community pharmacies, and that was very intentional. Antiretroviral therapy otherwise is generally available through the hospital system, and we said that would be a barrier because people will want to access PEP in different ways, through a private provider, through their general practitioner, through their sexual health clinic, through an online model if that proves to be successful, and Adam and I are working on that project together. So with that very intentional piece, we said it's going to be made available through community pharmacies. The other thing is recognising that it's a public health intervention, the medication was made available free, but also there was no dispensing fee, because for some individuals that will be a barrier. So it was never intended to be restricted, it's just that within the resources that we have now, that's how we were able to do it, and so we have increased significantly the number of GP PEP providers in the last number of years. As it stands right now, people will have to pay for the GP attendance, they won't have to pay for the medication, but within the strategy there is a very clear vision around having free access to sexual health services at point of access, and that is a piece of work that we are working with others to try to ensure that we can have free access to GP PEP care as well. Thanks very much. Thank you.