Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services A Report by Development Economics January 2013
About the Author Stephen Lucas is an economist with 20 years experience in economic, demographic and social policy and regeneration consulting. His expertise lies in economic impact assessment, economic regeneration, feasibility studies and project appraisal. Stephen is a co-founder and Managing Director of Development Economics Limited, a company that specialises in the economics of regeneration and social development policy. He regularly advises public and private sector clients and partnerships on economic strategy, project feasibility, impact assessment and funding. Recent government clients include: the Department for Communities and Local Government (DCLG), the Department for Work and Pensions (DWP) and the Scottish Government. Stephen has undertaken more than 50 Green Book-compliant economic appraisals and cost-benefit analyses of major infrastructure and development projects over the past eight years, representing total public sector investment of well over 10 billion. He also works extensively with the private sector, where recent clients have included Scottish Widows, Aviva, Visa Europe, Peel Holdings and Gladman Developments. 2 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Contents Foreword... 4 Executive Summary... 5 Commentary... 12 Section 1 Introduction... 14 Section 2 Context for the Study... 16 Section 3 The Potential Financial Costs to the NHS of Unintended Pregnancies... 21 Section 4 Other Public Sector Costs... 36 Section 5 Additional Longer-Term Economic Impacts... 49 Section 6 The Financial Costs and Wider Impacts of STIs... 57 Section 7 Key Findings and Implications... 69 Production of this report was funded and developed in partnership with Reckitt Benckiser Healthcare (UK) Ltd. Brook and FPA retained complete editorial control. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 3
Foreword Austerity measures have had an impact on our communities, our health, our education system and our pockets. The nation is in a period of great difficulty and everyone is feeling the pinch. Last year, we learnt from the Advisory Group on Contraception (AGC) about restrictions and cuts to contraceptive and sexual health services. As the UK s leading sexual health charities, Brook and FPA commissioned this report on the long-term financial implications of these cuts. The results have been startling. Policies that cut and restrict contraceptive and sexual health services now will result in greater numbers of unintended pregnancies and sexually transmitted infections (STIs). This will cost billions more in health and welfare expenditure in the future. But it doesn t have to be that way. A policy focus in the past on teenage pregnancy, chlamydia screening, sexual health and HIV means we know what to do to improve sexual health in the UK. That s why we ve launched the XES We Can t Go Backwards campaign to fight cuts and restrictions to services. Ensuring good access for all to contraceptive choices and accurate, evidence-based information on sexual health is essential if we are to improve the nation s health and reduce the cost of unintended pregnancy and STIs. We mustn t return to a time when such choices didn t exist. XES We Can t Go Backwards and this report show what could happen if we do. Simon Blake OBE Chief Executive, Brook Dr Audrey Simpson OBE Acting Chief Executive, FPA 4 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Executive Summary Access to the full range of contraceptive methods at a location and time that meets the needs of women is vital to minimise the risks and consequences of unintended pregnancy. But according to a report 1 published in April 2012 by the Advisory Group on Contraception (AGC), 3.2 million women aged between 15 and 44 experience restrictions in obtaining sexual health and contraceptive services. Their research found that the average abortion rate was around 9.7% higher in areas where services were restricted, compared with areas with no restrictions. This provides an indication that restrictions to contraceptive services could result in significantly more unintended pregnancies. Concerned by these findings, sexual health charities Brook 2 and FPA 3 launched the XES We Can t Go Backwards campaign to demonstrate the importance of high-quality contraceptive and sexual health services. Unprotected Nation The Financial and Economic Impacts of Restricted Contraception Services was commissioned as part of the XES campaign, and considers the potential financial consequences of increased restrictions on access to contraceptive and sexual health services in the UK. To understand this position in better detail, three scenarios are evaluated. These are based on current, improved and worsened access to services. Key findings based on maintaining current access levels of contraceptive and sexual health services show that, between 2013 and 2020, unintended pregnancy and STIs could cost the UK between 84.4 billion and 127 billion (Table S4) comprising: 11.4 billion (cumulative costs) of NHS costs as a result of unintended pregnancy and STI costs (Tables S1 and S2) between 73 billion and 115.3 billion (cumulative costs) of wider public sector costs (Table S3). If cuts continue and there is worsened access with more people being denied access to contraceptive methods and information the additional cost to the NHS plus wider public sector costs could total between 8.3 billion and 10 billion (Table S4). To put this in context the total NHS budget for 2012 13 was 108.8bn 4. If on the other hand there is improved access, cost savings to the NHS and public sector of between 3.7 billion and 5.1 billion could be made compared to the current access scenario (Table S4). Worsened access could cost 8.3bn 10bn more by 2020 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 5
Methodology To generate the findings presented in this report: an extensive review was undertaken of national and international trends in unintended pregnancy and STI rates, the health spending associated with these, and with the children born as a result of unintended pregnancy; a review was undertaken of available data on rates and trends for conceptions, abortions, miscarriages and STIs, and of Office for National Statistics (ONS) projections of the UK population; a range of plausible future scenarios for unintended pregnancy and the various alternative outcomes (abortions, live births etc) was developed; these scenarios were used to generate estimates of future health-related and nonhealth public expenditure. Three scenarios were used to consider the impact of restrictions to contraceptive services: i. the current access scenario considers the impact of maintaining (2011) rates and trends in unintended pregnancy and STIs; ii. an improved access scenario considers the impact of removing restrictions to contraceptive services, or improving the prevention of STIs; iii. a worsened access scenario considers the potential impact of increasing restrictions to contraceptive advice and methods, or increased diagnosis of STIs. NHS Costs Unintended Pregnancies Numbers of abortions, miscarriages and live births expected under each of the three scenarios, and the costs of these, were considered and these are shown in Table S1 overleaf. Based on current access levels, the annual costs of unintended pregnancies to the NHS between 2013 and 2020 will be 662 million; a cumulative total of more than 5.2 billion over 8 years (Table S1). 299m additional costs to the NHS from an increase in unintended pregnancies To put this figure in context, the costs for 2013 2015 alone amount to more than 2 billion, representing just over 10% of the 20 billion of efficiency savings the NHS needs to find by 2015. 5 If there was an improved access scenario with fewer restrictions on access to contraceptive services, the cost of unintended pregnancies to the NHS would be reduced by 24 million each year; cumulative savings of almost 196 million between 2013 and 2020. If there is worsened access, these costs could rise by around 299 million (6%) by 2020. 6 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Table S1: Unintended Pregnancy: Expected Outcomes and Cumulative Costs Under the Three Scenarios (based on 2011 prices) Indicator Scenario 1 Current Access Scenario 2 Improved Access Scenario 3 Worsened Access Number of unintended pregnancies (2013 2020), leading to: 3,544,596 3,467,430 3,601,570 Abortions (NHS only) Miscarriages Live Births 1,411,079 416,415 1,665,944 1,358,317 402,718 1,604,203 1,537,300 436,469 1,665,944 Cumulative costs 2013 2020 5,294m 5,098m 5,593m Average annual cost 2013 2020 662m 637m 699m Source: Development Economics STIs (excluding HIV) STI diagnoses in England increased by 49% between 2002 and 2011, though this increase can partly be accounted for by improvements in surveillance and diagnosis. For example, the significant increase in the number of cases of chlamydia that occurred in 2008 was largely the result of the introduction of more efficient methods of surveillance. Potential to save 1.13bn through better access to services Around 510,000 new STI diagnoses were made in the UK in 2011 6, with estimated treatment costs of 620 million. 7 This report considers three scenarios for future STI rates in the UK, as follows: If current rates of infections continue between 2013 and 2020, total public health spending of around 6.04 billion can be expected. Worsened access to services could lead to an increase in public health spending of 314 million to 6.35 billion, while improved access to services could result in cost savings of around 1.13 billion by 2020. (Table S2 overleaf) Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 7
Table S2: Summary of Cumulative Scenario STI Costs, 2013 2020, Scenarios 1 3 (based on 2011 prices) STI Scenario 1 Current Access Scenario 2 Improved Access Scenario 3 Worsened Access Chlamydia 2,320m 1,518m 2,560m Syphilis 13m 11m 14m Gonorrhoea 34m 34m 35m Anogenital warts 1,568m 1,363m 1,601m Anogenital herpes 313m 273m 338m Other STIs 1,792m 1,715m 1,807m Total 6,040m 4,914m 6,354m Source: Development Economics Combined Impact of Unintended Pregnancy and STIs If there is worsened access, the combined costs to the NHS of unintended pregnancy and STIs could be as high as 781 million by 2020. (Tables S1, S2 and post-natal healthcare figures from Table S3) Conversely, improved access to services could result in savings of up to 1.45 billion by 2020. (Tables S1, S2 and post-natal healthcare figures from Table S3) 8 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Public Sector Costs The medical costs of unintended pregnancy and STIs pale almost into insignificance compared to the wider public sector costs. For example, the cumulative medical costs based on current levels of access between 2013 and 2020 are an estimated 5.294 billion (Table S1), while public sector costs range from 73.079 billion to 115.363 billion (Table S3). Though this report considers costs between 2013 and 2020, education costs for children from unintended pregnancies apply to age 18, and could range from 98.7 billion (with worsened access) to 90.5 billion (with improved access). 8 Long-term spending requirements associated with unintended pregnancies such as policing, justice and antisocial behaviour are not covered by this report. Table S3: Cumulative Wider Public Sector Cost, Scenarios 1 3, 2013 2020 (based on 2011 prices) Indicator Scenario 1 Current Access Scenario 2 Improved Access Scenario 3 Worsened Access Expenditure area Minimum Maximum Minimum Maximum Minimum Maximum Social welfare 52,347m 66,996m 50,488m 64,588m 58,993m 74,147m Personalised social services 5,764m 23,650m 5,586m 22,933m 6,001m 24,602m Education 8,717m 10,374m 8,525m 10,145m 9,335m 11,109m Post-natal healthcare 2,264m 4,121m 2,194m 3,993m 2,357m 4,290m Housing 1,658m 7,894m 1,607m 7,650m 1,726m 8,219m Anti-poverty programmes 2,328m 2,328m 2,266m 2,266m 2,409 2,409m Total 73,079m 115,363m 70,665m 111,576m 80,821m 124,776m Source: Development Economics Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 9
Combined Costs Compared to the current access scenario, the additional cost of worsened access to contraceptive and sexual health services could lie between 8.3 billion and 10.0 billion by 2020, while improved access could save between 3.7 billion and 5.1 billion. (Table S4) By 2020, providing services to support children from unintended pregnancy could account for between 10% and 15% of the UK s anticipated social welfare spending. 9 3.7bn 5.1bn could be saved by 2020 by improving access to contraceptive and sexual health services Table S4: Cumulative Overall Public Sector Costs, Unintended Pregnancies and STIs, Scenarios 1 3, 2013 2020 (based on 2011 prices) Indicator Expenditure area Abortions, miscarriages, births Wider public costs STIs Total Scenario 1 Current Access Scenario 2 Improved Access Scenario 3 Worsened Access Minimum Maximum Minimum Maximum Minimum Maximum 5,294m 5,294m 5,098m 5,098m 5,592m 5,592m 73,079m 115,363m 70,665m 111,576m 80,821m 124,776m 6,040m 6,040m 4,914m 4,914m 6,354m 6,354m 84,413m 126,697m 80,677m 121,588m 92,767m 136,722m Source: Development Economics 10 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Impacts on Earnings and Poverty This report also considers the potential impact of unintended motherhood on the medium to long-term earnings of the mother. The table below summarises the potential loss of earnings under each of the three scenarios, including an estimate of lost income tax and national insurance contributions. Table S5: Potential Loss of Earnings and Income-related Tax Revenues, 2013 2020 (based on 2011 prices) Scenario Scenario 1 Current Access Scenario 2 Improved Access Scenario 3 Worsened Access Aggregate Annual Lost Earnings by 2020 Cumulative Lost Earnings 2013 2020 Cumulative Lost Tax Revenues by 2020-392m - 2,511m - 803m - 370m - 2,421m - 775m - 424m - 2,633m - 843m Source: Development Economics If current rates of unintended pregnancy continue, cumulative earnings lost between 2013 and 2020 will total just over 2.51 billion. Worsened access would mean a rise in lost earnings of 122 million by 2020, while improved access would mean a 90 million reduction in lost earnings. This estimated loss of earnings could have a knock-on impact on the UK economy of between 3.52 billion and 3.81 billion from 2013 to 2020. 10 3.52bn 3.81bn lost to UK economy by 2020 through loss of earnings Under the current access scenario, cumulative lost income tax and national insurance contributions would be around 803 million by 2020. If restrictions increase, losses could rise by 40 million by 2020; if access is improved, lost revenues will fall by 28 million. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 11
Conclusions This report was prompted by concerns that mounting financial pressures combined with imminent changes to commissioning structures are leading to reduced access to contraception and sexual health services around the UK. Our research clearly shows the significant cost of pursuing this approach. The financial implications of unintended pregnancy and STIs go far beyond short-term medical costs: they have a major impact on the medium- to long-term financial health of our country, and the physical health of its people. Commentary Anne Connolly, GP: Ridge Medical Practice, Bradford and Chair of the Primary Care Women's Health Forum Those of us who work on the front line of primary care and contraceptive services should be concerned about the impact of the imminent changes to commissioning, not least because decisions based in cost-efficiency will have direct implications for people s wellbeing. A significant amount of work has been undertaken since the teen pregnancy reduction target was set in 1998, with good results, but we continue to have high rates of unplanned pregnancies and increasing STIs due to the changing pattern of sexual behaviour. Restricted contraception services are already in evidence across the UK, with visible consequences. Recent work by the AGC demonstrated that in areas where restrictions on contraceptive availability are present, abortion rates are 9.7% higher than areas with no restrictions. This report reveals for the first time just how far-reaching these consequences are, and makes clear that continuing the progress made by decades of good work requires investment including better sex and relationships education in schools, and access to a full range of contraceptive methods through a number of providers. This report by Brook and FPA not only makes stark reading for clinicians concerned about the impact of increased restrictions on people s lives, but is also extremely relevant to those who are making the financial decisions, as the projected long-term ramifications for NHS and welfare budgets testify. The projected costs for continuing to increase restrictions are frightening, but if we are brave enough to invest money at a time when there is pressure to disinvest, and to ensure the money is spent wisely, this report provides compelling evidence that there are significant cost savings, as well as quality-of-life improvements, as the reward. 12 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
References of Executive Summary 1 Sex, Lives and Commissioning identified that around one third of women aged between 15 and 44 in England don t have access to comprehensive contraceptive and sexual health advisory services. 2 Brook is a registered charity that provides free sexual health services and advice to people under 25. 3 FPA, formerly the Family Planning Association, is a charitable organisation whose mission is to educate and inform about matters to do with sexual health and sexual health services in the UK 4 www.nhsconfed.org/priorities/latestnews/pages/budget-2012-key-points-nhs.aspx. 5 HM Treasury, Spending Review, 2010. 6 Unprotected Nation: The Financial and Economic Impacts of Restricted Contraception Services, Table 6-3, FPA and Brook 2013. (Based on data from Health Protection Agency 2012 and ONS 2012). 7 Unprotected Nation: The Financial and Economic Impacts of Restricted Contraception Services, Table 6-5, FPA and Brook 2013. (Based on information from Counting the Cost: the Economics of Sexually Transmitted Infections, the North West Public Health Observatory, March 2005 and The Health Service Cost Index, 2003 2011. 8 Unprotected Nation: The Financial and Economic Impacts of Restricted Contraception Services, paragraphs 4.39 and 4.40, FPA and Brook 2013. 9 Based on HM Treasury targets for 2013 2015 spending on welfare spending, extrapolated forward to 2020. 10 Unprotected Nation: The Financial and Economic Impacts of Restricted Contraception Services, paragraph 5.29, FPA and Brook 2013. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 13
Section 1 Introduction Objectives of the Report 1.1 A number of factors have combined that have the potential to create a crisis in numbers of unplanned pregnancies, abortions and sexually transmitted infections. These factors include: evidence of restrictions on the availability of some contraceptive services and contraceptive advice in some areas of the UK, including some methods of contraception only being made available with a GP referral concern that pressure on public health budgets and the drive for efficiency savings in health service delivery might mean these restrictions could become more widespread the discontinuation of relevant public health strategies, including the national sexual health strategy and the teenage pregnancy strategy, and the delay in the coalition government introducing replacement strategies a vocal campaign by some commentators and interest groups who appear to be seeking a curtailment of women s rights to access contraception and abortion services. 1.2 Given the growing concerns, this report has been commissioned by the two leading sexual health charities, Brook 1 and FPA 2, in collaboration with Reckitt Benckiser Healthcare (UK) Ltd. 1.3 This report identifies the potential financial and economic impacts of existing and potential future restrictions on the provision of contraceptive advice and services in some parts of England, and considers the potential consequences were these restrictions to be extended throughout the United Kingdom. 1.4 The report also quantifies the potential impact of reduced levels of contraceptive services and advice, and assesses the longer-term impacts of reduced levels of service on health and other public sector budgets between 2013 and 2020. 1.5 In addition, the report also considers the potential longer-term impacts of unintended pregnancy on the longer-term labour participation and earnings potential of both teenage and older mothers. 1.6 In terms of STIs, the report identifies the issues associated with a rising incidence of infections, and assesses the current level of direct medical costs of diagnosis and treatment, and considers three alternative future scenarios for financial liabilities between 2013 and 2020. 1 Brook is a registered charity that provides free sexual health services and advice to people under 25. 2 FPA, formerly the Family Planning Association, is a charitable organisation whose mission is to educate and inform about matters to do with sexual health and sexual health services in the UK. 14 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Structure of the Report 1.7 The remainder of this report is structured as follows: Section 2: provides the context for the study, including the evidence of restrictions of access to contraceptive services and advice in some parts of England Section 3: provides definitions of three forward-looking scenarios between 2013 and 2020, and identifies the potential financial costs to the NHS of increased demand for healthcare services associated with future levels of unintended pregnancies under each of the three scenarios Section 4: identifies the potential wider financial costs to the public sector such as social welfare payments, personalised social services, postnatal health costs, housing costs and education costs that are likely to be associated with future levels of unintended births under each of the three scenarios considered by this report Section 5: Section 6: Section 7: Sources of Data considers the potential impact of unintended births on the wider economy, including issues such as short-to-medium-term impacts on labour market participation, earnings and human capital formation, focusing in particular on contrasting the potential impact on younger mothers with women who have already completed their education and gained qualifications assesses the financial and wider economic impact of potential increases in the incidence of sexually transmitted infections that might result from worsened access to sexual health guidance, education, advice and counselling programmes provides a summary of key findings and discusses some wider implications. 1.8 The report utilises data from a range of sources, primarily the Office for National Statistics and other government departments, such as the Department of Health, the Department for Education, the Department for Work and Pensions, and HM Treasury. The report also utilises information from developed administrations such as the Scottish Government and National Assembly for Wales and from agencies such as the Health Protection Agency. 1.9 The research also utilises information from UK and international academic literature, including research from the United States and Australia, and from pan-national sources such as the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD), and European Union (EU) health protection and statistical agencies. 1.10 The various sources of data and information are cited throughout the report. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 15
Section 2 Context for the Study Recent Trends in Sexual and Reproductive Health 2.1 Sexuality is a key part of human identity, and good sexual health is an important component of physical and mental wellbeing. Over the past four decades or so there have been huge changes in population patterns of sexual behaviour in the UK, but some of these changes have led to increased risks of health problems, including rising rates of unintended pregnancy and sexually transmitted infections. Unintended Pregnancy and Abortion 2.2 Changes in patterns of sexual behaviour have led to a number of health and social problems, such as increased numbers of unplanned pregnancies, and Britain is notable for having one of the highest teenage pregnancy rates in Western Europe. 3 2.3 Abortion rates are often used as a proxy indicator of unintended pregnancy. The numbers of abortions performed in England and Wales for residents increased from around 75,000 in 1970 to over 189,000 in 2010 (an increase of almost 150%). This trend suggests that the total number of unintended pregnancies has also increased very substantially over the same period. 2.4 Data for abortions in England and Wales confirms that progress has been made over the past decade in reducing rates of abortion among teenagers and younger women. However, the same datasets indicate that abortion rates have risen over the same time period for older women, suggesting that rates of unintended pregnancy have been increasing among these older age groups. The table below sets out crude abortion rates by age group for 2011 compared to 2001 for England and Wales. Table 2-1: Crude Abortion Rates (per 1,000 women) England and Wales, 2001 and 2011 Age Group 2001 2011 % Change 2001 2011 Under 18 18.0 15.0-16.7% 18 19 32.1 28.8-10.3% 20 24 30.6 30.1-1.6% 25 29 20.9 22.9 9.6% 30 34 14.2 17.2 21.1% 35 or over 6.5 6.9 6.2% Source: ONS Abortion Statistics, 2011 3 From FPA Teenage Pregnancy factsheet (data sourced from United Nations Statistics Division, Statistics and Indicators on Women and Men, Table 2b, Indicators on Child-bearing, July 2010). 16 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
2.5 The data indicates that whereas for under 18s there has been a 16.7% reduction in crude abortion rates since 2001, and smaller reductions for women 18 19 (10.3%) and 20 24 (1.6%) respectively, there has been an increase in rates for each of the groups aged 25 and over. The increase is especially noticeable for women aged 30 34 (21.1%). Sexually Transmitted Infections (STIs) 2.6 Another issue of increasing concern is that the rates of incidence of sexually transmitted infections have been growing steadily in recent decades. The upsurge in the rates of incidence of STIs in England since 2002 is a component part of a longerterm trend over the past few decades. The increased incidence of STIs is attributable in part to changes in sexual behaviour, but also to increases in public health surveillance and testing, coupled with the introduction of more sophisticated diagnostic methods. 2.7 The increased rates of unintended pregnancy and STIs have led to commensurately increased levels of medical and other public expenditure. There are treatment costs for STIs that are diagnosed, and for dealing with the longer-term medical implications of cases that are not detected or treated. In the case of unintended pregnancy, as well as the medical costs of responding to increased demand for abortion, there are also medical costs associated with the proportion of unintended pregnancies that result in a live birth. 2.8 Unintended pregnancies that result in live births can also lead to significant levels of public expenditure, in terms of social welfare costs, education costs, housing costs and other forms of public spending. The extent of these costs is assessed in later sections of this report. Background to the Study 2.9 Despite the continued problems with high levels of teenage pregnancy, growing numbers of unintended pregnancies among women aged over 25, and increased rates of STIs, concerns are growing regarding a potential reduction in the range of accessible contraceptive advice and services available in the UK. The issues that have given rise to particular concerns include: some health service commissioners may be restricting access to contraceptive services and advice on the basis of age and/or place of residence the need to achieve efficiencies in health service delivery may result in reduced access to some methods of contraception, and in particular for some forms of long-acting reversible methods of contraception (LARCs) increasing evidence that some methods of contraception may only be available with a GP referral, and that some GPs don t offer a full range of services and a concern that changes to commissioning structures may result in adverse effects in terms of the continuity and quality of contraceptive advice and services. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 17
2.10 The Quality, Innovation, Productivity and Prevention (QIPP) agenda means that the NHS needs to find 20 billion of efficiency savings by 2015. 4 Health service commissioners are therefore under increasing pressure to achieve savings, or to do more with less, and there is mounting evidence that these pressures are resulting in restrictions on services, including contraceptive and sexual health services. For example, a freedom of information audit in April 2011 revealed that more than half of responding commissioners had a list of medications that GPs were banned from prescribing, including new forms of contraception. 5 2.11 In April 2012 the Advisory Group on Contraception (AGC) published the results of a survey into the commissioning of contraceptive and abortion services in England. The report, Sex, Lives and Commissioning, identified that over 3.2 million women of reproductive age (defined as 15 to 44 years) are living in areas where fully comprehensive contraceptive advisory services are not provided. 6 This means approximately one-third of women in England within this age range live in areas with restricted access to contraception advisory services or contraceptive methods that are most suited to their needs. 2.12 A key finding of the AGC research was that the average abortion rate in 2010 for women aged 15 to 44, in Primary Care Trust (PCT) areas where some form of restriction on contraceptive service availability was in place, was about 9.7% higher than in PCT areas where no restrictions were in place. 7 2.13 As a consequence, the All Party Parliamentary Group on Sexual and Reproductive Health in the UK (APPG) launched an inquiry into access to contraception in April 2012. Its subsequent report 8 identified a number of concerns, including: Evidence was found of worsening access to contraceptive services, particularly in relation to the age of women (such as restrictions on access to oral contraception for women aged over 25), restricting access to residents only, and restrictions on access to LARCs. The APPG also identified growing concerns regarding the impact of restrictions on contraceptive service delivery on the training (and availability of training) of healthcare professionals. Concerns were identified on the fragmentation of sexual health service commissioning, and the potential for adverse impacts on the quality of future service provision. 4 HM Treasury, Spending Review, 2010. 5 Pulse, GPs Face Bans on High Cost Drugs, 12 April 2011. 6 AGC: Sex, Lives and Commissioning, April 2012, p3. 7 AGC, Sex, Lives and Commissioning, April 2012, p18. 8 All Party Parliamentary Group on Sexual and Reproductive Health in the UK, Healthy Women, Healthy Lives? (2012). 18 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Potential Impacts of Restricting Contraception Services 2.14 The recent All Party Parliamentary Group report on Sexual and Reproductive Health in the UK stressed that women of different ages and in varying circumstances may require access to contraception in alternative forms and in a manner and at a time that suits their needs best. In order to minimise the risk of unintended pregnancy, it is important that contraceptive services are provided in a way that best matches these varying needs. 2.15 Over the past decade or so there has been particular emphasis placed on reducing the levels of teenage pregnancy in the UK. Teenage pregnancy matters greatly, for several reasons: because of health risks to both teenage mother and child because of the damage that teenage pregnancy and motherhood can have on the life chances of the teenage mother (for example, only 30% of teenage mothers are in employment, education or training, compared to 90% of all 16 to 19 year olds) 9 and because of the strong links between teenage pregnancy and social deprivation. 2.16 However, one unintended consequence of the focus of the teenage pregnancy strategy was that there may have been insufficient attention placed on the contraceptive needs of women aged 20 and over. Figures from the ONS confirm that over 80% of abortions take place for women over 20, and the data set out earlier in this section confirms that the number of abortions for women in this group has continued to rise over the past decade. 10 2.17 The focus of the research is to examine the potential financial, wider economic and social consequences of different levels of access to contraception advice and contraceptive methods. The study focuses on the potential impacts between 2013 and 2020. Focus of the Report 2.18 Given this context of increasing rates of unintended pregnancy and STIs, this report focuses on the potential financial and economic impacts of anticipated future constraints on the provision of contraceptive advice and sexual health services in England, and considers the potential consequences were these cuts to be extended across the United Kingdom as a whole. 2.19 In particular, the report focuses on a number of linked aspects associated with rising rates of unintended pregnancy, including the following: The potential impact of reduced levels of contraceptive services and advice on future numbers of unintended pregnancies between 2013 and 2020, the numbers of abortions, miscarriages and live births that would result as a consequence, and the net additional costs to the NHS that would accrue as a result. 9 Department for Health and DFES, Teenage Pregnancy and Sexual Health Marketing Strategy, p11. 10 ONS Abortion Statistics, 2011. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 19
For the additional live births that would result from increased numbers of unintended pregnancies, the report also assesses the potential impacts on public expenditure between 2013 and 2020, including expenditure on health care (post natal), education, welfare services, public sector housing costs, etc. The study also considers the wider economic consequences of unintended pregnancies leading to live births between 2013 and 2020, in terms of aggregate impacts on earnings potential, spending power, tax revenues and investment in human capital (skills and qualifications). 2.20 In terms of the issues associated with the rising incidence of sexually transmitted infections, the report focuses on the current levels of direct medical costs of STI treatment, and also considers three future scenarios for rates of STI diagnosis between 2013 and 2020. 2.21 The period 2013 to 2020 was selected as the main timeframe for the analysis in this report to provide a sufficient elapse of time for some of the medium-term implications of unintended pregnancy in particular to become manifest, but without focusing on an end point that is so far ahead in time that policy-makers and other stakeholders risk losing sight of the implications of the findings. 20 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Section 3 The Potential Financial Costs to the NHS of Unintended Pregnancies Introduction 3.1 This section aims: to provide some additional context for recent trends in unintended pregnancies in the UK (focusing in particular on data for England and Wales) to set out the basis upon which different scenarios for future rates of unintended pregnancies and outcomes for abortions, miscarriages and live births are based and to expand the scenarios, and set out the results for potential future medical costs of unintended pregnancies. Context Population Trends 3.2 ONS population projections (2010) have been used to estimate the number of females of child-bearing age in the UK. The table below sets out the projected numbers of females aged 13 through 19, and for age groups 20 to 24 up to 40 to 49, for each year from 2013 to 2020. 3.3 Overall, the number of women aged 13 to 49 in the UK is expected to decline slightly between 2013 and 2020, from 15.463 million (2013) to 15.248 million (2020). This represents a reduction of 1.39% in the relevant female population over this period. 3.4 When more tightly defined age groups are considered, the trends are more mixed: for example, there is expected to be an increase of around 5.5% in the numbers of teenage girls aged 13 15, but a decline in the numbers of 16 19-year-olds by around 6.6%. Also, the numbers of females 30 39 is expected to increase by 12%, but those 40 49 are expected to decline by about the same proportion. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 21
Table 3-1: ONS Population Projections 2013 20: Number of Women ( 000s) Age 2013 2014 2015 2016 2017 2018 2019 2020 13 334.5 329.1 328.1 335.8 348.2 353.7 360.6 371.7 14 344.5 335.0 329.6 328.6 336.2 348.7 354.1 361.1 15 351.9 345.4 335.9 330.5 329.5 337.1 349.6 355.0 16 361.4 353.2 346.8 337.2 331.8 330.8 338.4 350.8 17 361.2 364.0 355.8 349.3 339.7 334.3 333.3 340.9 18 366.8 366.0 368.7 360.5 353.9 344.3 338.9 337.8 19 383.5 374.2 373.3 375.9 367.5 361.0 351.4 345.9 20 24 2,129.2 2,118.9 2,092.0 2,058.5 2,032.3 2,010.1 1,986.6 1,963.2 25 29 2,218.7 2,253.4 2,274.4 2,294.4 2,307.9 2,296.7 2,283.1 2,254.0 30 34 2,067.2 2,107.1 2,144.9 2,181.8 2,223.8 2,275.8 2,308.4 2,327.8 35 39 1,927.9 1,926.8 1,955.9 1,999.2 2,046.3 2,087.4 2,126.0 2,163.0 40 49 4,616.0 4,543.4 4,456.7 4,362.5 4,259.0 4,173.4 4,108.2 4,076.5 Source: ONS population projections, 2010 Statistics for Unintended Pregnancy 3.5 There are no official statistics that measure the rates of unintended pregnancy in the UK. It is possible, however, to estimate the number of unintended pregnancies by using available statistics on abortions and a number of additional assumptions. 3.6 Abortion rates are an indicator of rates of unintended pregnancy, but they are obviously also influenced by cultural and legal considerations. Overall, there has been a rising trend in long term abortion rates over the past three decades. For England and Wales, the age standardised rate of abortions per 1,000 resident women aged 15 44 has increased from 8.0 in 1970 to 17.5 in 2010. 3.7 In terms of numbers of abortions, the actual increase reflects both an increased rate of abortions and a (smaller) rate of increase in the number of women of child-bearing age. The actual numbers of legal abortions in England and Wales has increased, according to ONS abortion statistics, from 75,962 in 1970 to 189,574 in 2010. 3.8 The largest share just over 50% of abortions is for women aged 20 29. Teenagers contribute about 20% of the total, with the remaining 29% made up of women aged 35 or over. 22 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Table 3-2: Numbers of Legal Abortions by Age Group, Residents of England and Wales, 2010 Age Group Number of Abortions Proportion of Total Under 16 3,718 2.0% 16 19 34,551 18.2% 20 24 55,481 29.3% 25 29 40,800 21.5% 30 34 27,978 14.8% 35 or over 27,046 14.3% Total 189,574 100.0% Source: ONS Abortion Statistics, 2011 3.9 Statistical evidence indicates that the number of teenage pregnancies has been falling in recent years. Moreover, the conception rate among under 18s has also fallen, from 47.1 per 1,000 in 1998 to 35.5 per 1,000 in 2010. 11 3.10 Nevertheless, there are still large numbers of unintended pregnancies among under- 18s, and compared to other Western European countries the conception rate among females under 18 years in the UK is still high. 3.11 Given that there are no official statistics on unintended pregnancies, it is necessary to estimate their number. The main assumption used here is based on written evidence presented to Parliament s Health Select Committee in 2010 by Bayer Schering Pharma 12, which itself was based on evidence gathered by the National Institute for Health and Clinical Excellence (NICE) in 2005, which found that 40.6% of all unintended pregnancies end in abortion. It is also taken as a given that 100% of conceptions for females under 16 are unintended because of their age, as the legal age of consent is 16, and that 80% of conceptions among 18 and 19 year olds are unintended. 3.12 The approach to estimating the number of unintended pregnancies is to divide the number of abortions performed on adult women by a factor of 0.406. To these are added all conceptions for females aged 17 and under, and 80% of conceptions for females aged 18 and 19. 3.13 Based on these assumptions it is estimated that there are likely to have been around 450,000 unintended pregnancies in the UK in 2011. Of these, under-16s are likely to have contributed 1.7% of the total, with 16 19 year olds providing a further 18.7%. The majority of unintended pregnancies are likely to have arisen from women aged 20 29. 11 ONS Conception Statistics, 2012. 12 www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/1020/1020w138.htm. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 23
Table 3-3: Estimates of the Numbers of Unintended Pregnancies in the UK, 2011 Age Group 2011 Proportion of Total Under 16 7,536 1.7% Source: Development Economics 16 19 84,298 18.7% 20 24 128,120 28.4% 25 29 91,587 20.3% 30 34 63,436 14.1% 35 39 39,921 8.9% 40 49 35,560 7.9% Total 450,459 100.0% 3.14 For women aged over 19, around 41% of unintended pregnancies end in abortion. A further 13% are estimated to end in miscarriage, with the remaining 46% resulting in a live birth. Based on the estimates set out in the table above, the overall estimates for outcomes are summarised in the following table. Table 3-4: Estimated Outcomes of Unintended Pregnancies in the UK, 2011 Abortions Miscarriages Live Births 182,886 58,560 209,013 Source: Development Economics Medical Costs of Unintended Pregnancies 3.15 It is possible to calculate estimates of the medical costs of unintended pregnancy using assumptions developed by Bayer Schering Pharma 13, originally based on those made in NICE guidance published in 2005. The 2005 cost estimates have been adjusted to 2011 price levels based on average rates of health sector inflation between 2005 and 2011. 14 3.16 In the table below, we set out the assumed medical costs of each of the three main outcomes of unintended pregnancy. 13 Bayer Schering Pharma, Focus: Tackling Unintended Pregnancy, spring 2008. 14 Prices have been adjusted to 2011 levels using assumptions based on Health Service Cost Index Annual Summary 2011/12. 24 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Table 3-5: Assumed Average Medical Costs of Pregnancy Outcomes (2011 prices) Per Live Birth Per Miscarriage Per Abortion 2,574 387 599 Source: Bayer Schering Pharma: Focus: Tackling Unintended Pregnancy, spring 2008, based on NICE Clinical Guidelines No 30 (2005); prices adjusted to 2011 levels using assumptions based on Health Service Cost Index Annual Summary 2011/12 3.17 Based on these assumptions, the estimated overall annual medical cost of unintended pregnancy in 2011 is estimated to be around 662 million (2011 prices). The largest shares of these costs are expected to be live births (estimated at just over 536 million) and abortions (nearly 106 million). Table 3-6: Estimated Cost of Unintended Pregnancy, UK, 2011 (2011 prices) Outcome Source: Development Economics Cost ( millions) Abortions 105.7 Miscarriages 19.6 Live births 536.3 Total 661.6 The estimates in the table above are broadly in line with other recent estimates. For example, the AGC report of April 2012 estimated that the costs to the NHS in England of unintended pregnancy for women aged 20 and over was 440 million. 15 The estimates here extend to the whole of the UK and cover teenage women as well. Future Scenarios for Unintended Pregnancies 3.18 To assess potential cost implications for the NHS of future rates of unintended pregnancy it is necessary to develop a range of plausible alternative scenarios for the rate of unintended pregnancy in the UK between 2013 and 2020. 16 15 AGC, Sex, Lives and Commissioning, April 2012, p7. 16 2020 was selected as the end year of analysis because it provides an eight-year period of analysis which is long enough for most forms of direct and indirect cost to become manifest. The main exception is the potential impact on antisocial and criminal behaviour, but taking these into account would require a much longer analytical framework, extending to 15 20 years and beyond. Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 25
3.19 Three scenarios have been designed to assess the three different profiles of costs associated with unintended pregnancy: 1. A current access scenario, that considers the potential impact on future costs assuming that rates of unintended pregnancy and associated outcomes (abortions, miscarriages, live births) continue to occur at the current (2011) rates throughout 2013 to 2020. In effect, this scenario models the potential impact of the 2011 (current) access levels throughout 2013 to 2020, but it also reflects the underlying demographic trend in terms of the numbers of women of child-bearing age 17 that are anticipated to be resident in the UK over the relevant period. 2. An improved access scenario, that considers the potential impacts of removing some of the restrictions on access to contraceptive services and choice that have been identified in some areas, and if some of the recent national trends towards improvement in associated performance indicators (especially for teenage pregnancy) were maintained and extended to older age groups of women. 3. A worsened access scenario, that considers the potential impacts on the same indicators, assuming that existing restrictions on access to contraceptive services and choice become more widespread and embedded, and that rates of unintended pregnancy among all age groups of women up to 49 years increase as a result. Projections for Unintended Pregnancy 3.20 Based on the projected number of women of child bearing age (broken down into individual years for women aged 13 19, and into five-year groups for women aged 20 24 up to 35 39, and a ten-year group for women aged 40 49), it is possible to generate estimates for the number of unintended pregnancies by age group for women in the UK between 2013 and 2020 under each of the three scenarios. 3.21 Based on this approach, the expected annual total of unplanned pregnancies over the next eight years under Scenario 1 is anticipated to lie between 440,000 and 446,000, for Scenario 2 between 413,000 and 438,000 per annum and under Scenario 3 between 448,000 and 461,000. 3.22 The cumulative number of unplanned pregnancies between 2013 and 2020 for each scenario is 3.544 million (Scenario 1), 3.414 million (Scenario 2) and 3.648 million (Scenario 3). 17 This report focuses on conception rates for women for the age range 13 years to 49 years. 26 Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services
Table 3-7: Expected Number of Unintended Pregnancies, 2013 2020 Table 3-7: Expected Number of Unintended Pregnancies, 2013 2020 (Source Development Economics) Age 2013 2014 2015 2016 Scen. 1 Scen. 2 Scen. 3 Scen. 1 Scen. 2 Scen. 3 Scen. 1 Scen. 2 Scen. 3 Scen. 1 Scen. 2 Scen. 3 13 354 322 360 348 302 355 347 286 355 355 277 365 14 1,789 1,714 1,820 1,739 1,631 1,776 1,711 1,569 1,753 1,706 1,529 1,754 15 5,669 5,545 5,792 5,566 5,383 5,710 5,412 5,176 5,576 5,325 5,034 5,509 16 12,026 11,580 12,334 11,755 11,102 12,117 11,540 10,685 11,955 11,223 10,184 11,683 17 18,398 17,930 18,892 18,541 17,833 19,138 18,124 17,202 18,805 17,793 16,661 18,557 18 23,796 23,312 24,186 23,745 23,021 24,264 23,922 22,949 24,575 23,386 22,197 24,151 19 26,919 26,919 27,352 26,272 26,272 26,835 26,208 26,208 26,910 26,390 26,390 27,239 20 24 121,396 120,012 122,110 121,317 119,244 122,747 120,577 117,833 122,718 119,612 116,212 122,460 25 29 93,887 92,617 94,453 94,835 92,912 95,974 95,338 92,764 97,051 95,795 92,566 98,085 30 34 68,105 67,483 68,528 68,949 68,008 69,802 69,666 68,406 70,953 70,348 68,765 72,073 35 39 38,984 38,534 39,227 39,039 38,364 39,527 39,355 38,450 40,090 39,808 38,667 40,793 40 49 33,198 32,541 33,393 32,998 32,024 33,389 32,698 31,416 33,283 32,361 30,784 33,139 Total 444,521 438,511 448,447 445,104 436,096 451,634 444,898 432,942 454,025 444,102 429,265 455,809 Age 2017 2018 2019 2020 Scen. 1 Scen. 2 Scen. 3 Scen. 1 Scen. 2 Scen. 3 Scen. 1 Scen. 2 Scen. 3 Scen. 1 Scen. 2 Scen. 3 13 368 271 380 374 258 387 381 247 396 393 410 237 14 1,746 1,528 1,801 1,810 1,547 1,874 1,839 1,533 1,910 1,875 1,954 1,524 15 5,309 4,961 5,515 5,432 5,016 5,666 5,632 5,140 5,900 5,720 6,016 5,157 16 11,042 9,815 11,552 11,008 9,581 11,573 11,262 9,593 11,897 11,675 12,394 9,729 17 17,305 15,984 18,141 17,027 15,512 17,942 16,976 15,249 17,978 17,364 18,483 15,377 18 22,959 21,558 23,836 22,337 20,747 23,312 21,984 20,195 23,064 21,919 23,114 19,912 19 25,801 25,801 26,770 25,339 25,339 26,426 24,667 24,667 25,857 24,285 25,587 24,285 20 24 118,904 114,853 122,459 118,253 113,560 122,512 117,470 112,145 122,422 116,575 122,207 110,630 25 29 96,136 92,252 99,004 95,869 91,358 99,306 95,483 90,352 99,481 94,654 99,197 88,936 30 34 71,147 69,234 73,316 72,104 69,856 74,726 72,655 70,075 75,724 72,903 76,411 69,998 35 39 40,315 38,932 41,553 40,743 39,116 42,235 41,114 39,242 42,861 41,432 43,431 39,312 40 49 32,003 30,142 32,973 31,695 29,555 32,855 31,432 29,015 32,781 31,257 32,792 28,555 Total 443,035 425,332 457,300 441,991 421,446 458,815 440,894 417,453 460,271 440,051 461,997 413,652 Source: Development Economics Unprotected Nation The Financial and Economic Impacts of Restricted Contraceptive and Sexual Health Services 27