How might A&E departments without targets work? Look to sexual health clinics

Will the secretary of state for health and social care get away with such barefaced shamelessness in his apparent plans to abolish waiting-time targets for A&E? Matt Hancock’s faintly plausible excuse is that the four-hour target is a perverse incentive to treat an ingrown toenail, at three hours and 50 minutes, ahead of heart attacks and road accident victims. But most A&Es triage efficiently, diverting minor ailments to GPs on site; their real crisis is 12-hour trolley waits for very ill people queuing for reduced numbers of hospital beds.

A&Es are the thermometers of the NHS, and they reached boiling point long ago, embarrassing a government that has starved the service of funds as never before in its history. Hancock and the prime minister now regularly speak of the NHS receiving its “biggest cash boost” in history, a factoid that describes half a glass of water offered in a drought.

In many unreported corners of the NHS that are less photogenic than A&E, the abolition of targets may not be a new habit. You can’t get much more hidden from view than sexual health clinics. There was a target to give every patient access within 48 hours, counting numbers unseen in that time. But that target “has been quietly dropped” says Dr John McSorley, of the British Association for Sexual Health and HIV. Now, he says, despite rising cases of gonorrhea and syphilis, up by 20% in England between 2016 and 2018, many patients face “multiple turnaways” from one clinic after another. With funding for sexual health cut significantly, he says clinics now “demand-manage”.

“We no longer have booked appointments, so patients self-select for the seriousness of their condition by willingness to wait for hours.”

More are treated online, where they are sent a package to return samples to labs, with online prescriptions. But even that is strictly rationed: “With no money to pay for it, some councils only allow 10 cases a day online. People have to get online straight after midnight. Fifteen minutes later, all 10 slots are gone, and they have to wait to try again the next night at midnight.”

Sexual health services were a casualty of the disastrous Health and Care Social Act 2012, which fragmented services: it stripped all public health from the NHS to hand over to local authorities. Then the ringfence was taken off the funding, so cash-strapped councils cut, and cut again.

“I don’t blame them”, says McSorley. “Local authorities are banned from debt, so they’re making the hardest choices, between cutting a clinic or closing a library.” Councils are due no extra money in the budget, beyond a sticking plaster for social care.

A recent health select committee report shows how an overall fall in sexually transmitted infections (STIs) – very good news – is due to the brilliant success of eradicating genital warts with the HPV vaccine for young people. But the figures conceal a rise in other clinic-treated STIs – such as chlamydia, which causes pelvic inflammatory disease and infertility in women. There has been 22% drop in young people being screened for chlamydia since 2014, while just over a quarter of local authorities have reduced spending on STI testing and treatment services by a fifth or more.

The good news is a steep fall in new transmissions of HIV, down by 73% from 2014 to 2018: government figures out today show how effective antiretroviral drugs have been for those with HIV and how effective pre-exposure prophylaxis (PrEP) is to protect those at risk from HIV infection. However, an estimated 7,500 people are living with HIV but unaware of it: two in five of those diagnosed in 2018 were already at a late stage, which comes with a tenfold increased risk of death within a year.

Related: Prostate cancer deaths in UK hit record high of over 12,000 in 2017

Here’s an odd slipperiness in these official figures: note that today’s report comes from Public Health England, and yet unusually the press release puts the emphasis on the whole UK. Why? Because England’s figures are far worse than Scotland and Northern Ireland’s – because only England has yet to make PrEP available to all at risk, while anyone can get the drug in Scotland and Northern Ireland. Only those on a special trial get it in England; others have to pay privately. The pills themselves are cheap, but clinic costs to supervise treatment are higher. The English health secretary strongly resisted the cost of treating all who could be protected. The target to stop any new transmissions by 2030 is easily achievable: these drugs are so effective that no one need die. Scotland and Northern Ireland show how many more come forward for tests and treatment when these are offered for free. Nonetheless, in his press release today, Hancock proclaims his “unwavering commitment to prevention”.

If he thinks the public don’t care much about STIs, a grubby service for dubious people, here’s something to frighten everyone. Anti-microbial resistance is appearing in gonorrhoea: “We are on a slippery slope to losing it,” McSorley warns. And anti-microbial resistance spills over into other diseases. A collapsing sexual health service is a danger to all.

• Polly Toynbee is a Guardian columnist