The early years
The 10-year strategy was developed over an 18 month period by the then Labour Government’s newly established Social Exclusion Unit (SEU), informed by a detailed review of the international and national evidence, interviews with national stakeholders, and consultations with professional organisations, NGOs and young people. It was published in 1999 with a 30-point action plan, across four themes: joined up action at national and local levels; better prevention for both girls and boys through improved sex and relationships education and access to effective contraception; a national communications campaign to reach young people and their parents and carers; and coordinated support for young parents [4]. The support programme was an important contribution to the prevention strategy, but the details are not reported in this article (but see [5]).
The headline target was to halve the under-18 conception rate between 1998 (the selected baseline year) and 2010.
A Teenage Pregnancy Unit (Unit) was established with cross-government funding to lead the implementation of the strategy, with a team combining civil servants and external experts drawn from the statutory sector and NGOs. The Department of Health held the national ministerial lead; however, to signal government’s collective responsibility for the strategy’s implementation, a minister for teenage pregnancy was appointed in each department and an inter-departmental group of officials met quarterly with TPU to monitor progress. Regional and local structures mirrored the national structure, with Regional Teenage Pregnancy Coordinators (regional coordinator), local Teenage Pregnancy Coordinators (local coordinator) and local Teenage Pregnancy Partnership Boards (partnership boards).
An Independent Advisory Group on Teenage Pregnancy (Advisory Group) consisting of expert stakeholders was appointed to monitor implementation of the strategy, to advise ministers on a regular basis and to submit an annual report to government. The strategy was supported by a group of NGOs and a national inter-faith forum [6].
An annual local implementation grant was provided to each of the 150 local government areas (average population size – 375,000, range 34,000 to 1,100,000), averaging 300–400,000 GBP. The grant was intended to supplement, not replace, mainstream funding with conditions on spending mandating the appointment of the local coordinator and partnership board, developing local plans and providing an annual report on progress [6].
To support local government and partners to work together, the strategy action plan tasked the Unit to publish a range of guidance on the following topics:
-
➢ sex and relationships education in schools [7];
-
➢ young people friendly sexual and reproductive health services [8];
-
➢ improving the uptake of sexual and reproductive health (SRH) advice by boys and young men [9];
-
➢ improving the uptake of SRH advice by black and minority ethnic young people [10];
-
➢ teenage pregnancy and diverse communities [11];
-
➢ making general practice young people friendly [12];
-
➢ confidentiality of services [13];
-
➢ setting up school [14] and college [15] based sexual health services; and
-
➢ involving young people in developing local strategies [16].
Specific guidance was also developed for youth support workers [17] and social care practitioners [18] on supporting young people to access SRH advice, as well as encouraging greater involvement of young people in local policy development. Funding was also made available for teachers and school nurses to participate in a national continuing professional development (CPD) programme to improve the quality of SRE [19, 20].
Communications campaign activities, informed by academic research, included - Sex. RUthinking about it enough? –aimed at 13 to 17 year olds, with headline messages on resisting peer pressure to have early sex, encouraging early access to confidential services and using condoms and contraception to prevent pregnancy and STIs; articles and advice in teenage magazines provided greater detail. A free telephone helpline for young people (Sexwise) was available from 7 am to midnight, 7 days a week. A separate initiative – Time to Talk - encouraged parents to talk to their children about sex and relationships and was delivered through Parentline Plus, an NGO trusted by parents [6].
The strategy’s action plan also included a commissioned research programme to explore issues identified by the SEU report as requiring more understanding [21].
Progress of the strategy was monitored through the quarterly and annual conception data and through the annual reports and performance management process led by the regional coordinators and the Unit. The reach of the campaign was monitored through an annual tracking survey. Independent academic researchers were commissioned to evaluate the first 4 years’ implementation of the strategy [22].
Mid-course review
By 2005, the national under-18 conception rate had declined by 11% but there was wide variation in progress, with local authority rates varying between a reduction of 42% and an increase of 43%. This prompted a ‘deep dive’ review of six areas, led by the Unit and the Prime Minister’s Delivery UnitFootnote 1 [23]. Three matched areas where rates had declined and three where rates had increased were compared. Each area was visited over 2 to 3 days by a team from the Unit and experts from the IAG, and detailed interviews and focus groups were conducted with senior leaders, service managers, frontline practitioners and young people. The review found that areas with larger reductions were implementing most, if not all, aspects of the strategy, involving all relevant agencies to create a ‘whole systems’ approach, with strong senior leadership; this contrasted with areas showing increases in rates.
Drawing on the review, Government issued new more prescriptive guidance for local areas, setting out the ten key factors for an effective local strategy (Fig. 1), together with detailed local data analysis and information to strengthen targeted work with the most vulnerable young people [23]. A self-assessment toolkit was provided to help areas identify and address gaps in their local plans and strengthen local performance management [24]. Additionally, a number of areas were placed under close ministerial scrutiny, received additional support from the regional coordinators and a Department of Health National Support TeamFootnote 2, and were invited to national meetings to share good practice. Six monthly reports on progress were requested by ministers [25].
The Unit also reviewed the national campaign. A redesigned RUthinking campaign continued to provide universal messages for younger teenagers and a new campaign, Want Respect?: Use a Condom, was developed for older teenagers, with a focus on boys and those most at risk [26]. The Sexwise helpline continued to provide confidential advice and referrals to local services, with half of the calls received being from boys and young men. Campaign materials were free for local areas to use in relevant settings. Further partnerships were developed with the private and commercial sector to link the Want Respect? messages with brands popular with the target group [26]. The Time to Talk campaign for parents continued with posters and leaflets disseminated through 10,000 general practice/family doctor surgeries [27].
No additional strategy funding was provided to local areas but an increasingly supportive policy environment strengthened the traction of the new guidance and ministerial focus. New legislation [28] put a legal duty on local areas to cooperate with partner agencies and promote Every Child Matters (ECM) - a more joined up and holistic approach to improving the health, education and wellbeing of children and young people. Each area formed a Children’s Trust with a requirement to develop a Children and Young People’s Plan to meet the five ECM outcomes, which included reducing the under-18 conception rate [29]. To reflect the more integrated approach, the Unit was moved from the Department of Health to a new Children, Young People and Families Directorate in the Department of Education and Skills, which later became the Department for Children, Schools and Families. The strong partnership work continued with the Public Health Minister in the Department of Health highlighting the importance of collective responsibility for progress [19].
The reach of the strategy was also increased through other Government programmes, including
-
➢ a new public health programme which provided additional investment in sexual health improvements [30];
-
➢ the continued implementation of the all age Sexual Health and HIV Strategy [31];
-
➢ a strengthened Healthy Schools programme which required schools to deliver a planned SRE programme to achieve a National Healthy Schools Standard [32];
-
➢ an expectation of all schools to develop extended services, including health drop-ins [33];
-
➢ a new Targeted Youth Support programme to reach vulnerable young people [34]; and
-
➢ the You’re Welcome quality criteria for the commissioning of young people friendly health services [35].
In 2007, in addition to the new guidance and ministerial focus on improving local performance, further consideration was given to what national government action would help accelerate progress. Following an updated international research review, the decision was taken to focus on the two key areas with the strongest empirical evidence on reducing teenage conception rates: improving the provision of high quality comprehensive SRE [36], and increasing uptake and effective use of contraception [37].
From the start of the strategy there had been a sustained call to government from the Advisory Group, the Sex Education Forum and other stakeholders, to make PSHE and SRE a statutory part of the school curriculum. Two reports from the school inspection service – OfstedFootnote 3 - had also highlighted SRE as the weakest element of PSHE, calling for significant improvements in the quality of teaching and assessment of students’ learning [38, 39]. Statutory status was considered essential to address the inconsistent provision and unacceptable variation for young people in whether or not they received appropriate SRE. Following an influential survey of 20,000 young people led by the UK Youth Parliament [40], and a Sex Education Forum campaign [41], Government commissioned a review of SRE and PSHE, and included representatives from a wide range of organisations, including faith groups [42].
In 2008, ministers accepted the review recommendations to make SRE and PSHE statutory [43], but the legislation failed to get passed during the final legislative process in April 2010 that preceded the general election. However, the expectation of statutory status prompted some local areas to raise the priority of SRE and develop programmes and training to prepare schools.
The focus on improving young people’s access to, and effective use of, contraception was highlighted by the trend in the under-18 conception data; the decline in births to under 18 s was faster than the overall decline in conception rates implying that greater access to contraception was required [44]. To support improvements, the Department of Health secured £33 million additional funding from the government’s Comprehensive Spending Review settlement for 2008-11 [45], with the aim being to increase access to all types of contraception, but particularly to ensure that Long Acting Reversible Contraception (LARC) choices were well publicised and easily available in local areas to women of all ages, including those under 18. Funds were distributed regionally with a focus on improving access for young people, and on activities such as health professional training on LARC fitting, which would be sustainable beyond the 3-year lifetime of the earmarked funding [45]. To continue the important promotion of condoms to protect against STIs and involvement of boys and young men, guidance was published on local condom distribution schemes [46], with special attention being paid to outreach work [47].
As part of the drive to improve awareness and uptake of effective contraception, and to increase awareness and screening of STIs, a new national campaign was launched – Sex. Worth Talking About. The campaign was informed by a marketing review [48] which showed that the previous targeted campaigns of Ruthinking and Want Respect? had increased awareness and improved behavioural intentions towards safer sex, but that the greatest impact of a national communications campaign would be achieved by promoting and modelling a more open culture around reproductive and sexual health advice. The campaign ads showed everyday conversations about contraception and chlamydia between young people, with parents, and with professionals, on radio, cinema and TV, and were broadcast at times to reach the widest possible audience. Materials reinforcing the campaign messages were available free to local areas [49]. Further partnerships were developed with the private and commercial sector including distribution of a leaflet for parents, Talking to your teenager about sex and relationships [50] through 3000 independent pharmacies. Pharmacies were chosen as a non-threatening and trusted source of health advice with a presence in all local communities, including the most deprived. The campaign was launched in November 2009 but only ran for a few months before the change of government in May 2010.
The impact of these strategy activities was again strengthened by an increasingly supportive policy environment, which helped to integrate teenage pregnancy work into wider programmes for improving the health and wellbeing of children, young people and families. The under-18 conception rate was included as one of five indicators in a new national government Public Service Agreement, a new Child Health Strategy [51] highlighted the importance of reducing teenage pregnancy, and a national and regional team supported local implementation of the You’re Welcome standards. New legislation [52] which placed a duty on school governing bodies to promote pupils’ wellbeing provided an incentive for schools to review and develop their SRE and PSHE policies. The Sex Education Forum was funded to develop a resource for schools to audit pupils’ views on the extent to which SRE was seen to meet their needs [53].
Progress in reducing the under-18 conception rate continued to be included in the performance frameworks of health, social services and local government. A revised self-assessment toolkit was published with an edited data set for monitoring progress [54]. Completion of the self-assessment was included as a marker of local government commitment to teenage pregnancy in the Comprehensive Performance Assessment rating. Local government’s increasing prioritisation of teenage pregnancy was highlighted in their autonomous choice of indicators for monitoring local progress (Local Area Agreements), with the under-18 conception rate chosen by 106 of the 150 areas [45].
Visible ministerial leadership at national and regional events and media interviews provided a backdrop illustrating government’s sustained commitment to teenage pregnancy [45]. Areas with slow progress continued to receive additional support from the regional coordinators and the National Support Teams.
Further guidance was published in February 2010, informed by an updated evidence review and lessons from effective local practice [55]. The guidance included some national commitments to support further progress, including legislation for statutory SRE. However, the majority of these were not implemented due to the change of government after the general election in May 2010.
The measure of progress for the strategy was the under-18 conception rate, published at national and local area levels. The latest data for 2014, published in March 2016, showed a 51% reduction in the under-18 conception rate from 1998 [56]; all local areas, including those with high deprivation, experienced reductions; and maternity and abortion rates were declining in parallel (Fig. 2). Although national data on other indices are limited, there was a doubling in the number of youth specific community contraceptive clinic sessions between 1997/8 and 2009/10 [57, 58], a large increase in the use of LARCs by under 18 s accessing contraceptive clinics [58], a significant expansion in the number of school and college based clinics providing reproductive and sexual health advice [59, 60] and an upward trend in the proportion of young people reporting school as their main source of SRE [61], which is associated with lower under-18 conception rates and STI diagnoses.
As Fig. 2 illustrates, the reduction in the conception rate accelerated after 2008. Interestingly, the downward trend continued despite the impact of the recession. During the UK recession in the early 1980s, there had been an increase in the under-20s conception – mainly maternity – rate [62]. Based on the trend in the 1980s, and the strong association between teenage pregnancy and deprivation, government scenario planning for the 2008 recession predicted a reversal of the downward trend; however, the data did not follow the anticipated pattern. Between 2008 and 2014, the conception rate fell by a further 42.5%, with both abortion and maternity rates declining. The contributory factors to this later decline are discussed in the next section.
