Memorandum by Mr Graham Taylor (SH 156)
ROLE IN
THE ORGANISATION
AND ANY
RELEVANT BACKGROUND
— Manages the HIV treatment and care
allocation and the HIV prevention allocations on behalf of the
local PCT's through an accountability framework.
— Manages the Public Health Laboratory
Service contract—(viral load tests etc), British Pregnancy
Advisory Service (terminations contract) and the Family Planning
contract for Brighton & Hove.
— Co-chair of the Section 31 group
developing integrated HIV community team currently consisting
of the HIV Psychiatric team, HIV Community Nursing Team, and the
HIV Social Services Specialist Team.
— Jointly manage the Aids Support Grant
Service Level Agreements with East Sussex County Council and with
Brighton & Hove Council.
— Responsible for implementing (with
the local PCT leads) the National Sexual Health & HIV Strategy
and for developing five local Sexual Health & HIV action plans
(one for each PCT), and develop the five sexual health elements
of the three year planning cycle (one for each PC).
— PCT "lead" for the Teenage
Pregnancy Strategy working closely with the local teenage pregnancy
co-ordinators for Brighton & Hove and East Sussex.
— Practice Manager of a central London
GP practice.
— Primary Care Manager "managing"
the allocation of GMS monies to GPs.
— Director of a voluntary organisation,
providing in-patient and day care services for people who are
HIV+.
THE ORGANISATION
AND LOCAL
PICTURE
— Employed by Brighton & Hove City
Primary Care Trust, in a shared services arrangement with East
Sussex PCTs.
— Brighton & Hove PCT is co-terminous
with Brighton & Hove unitary Authority, however there are
four PCTs within East Sussex County Council area. Some PCTs commission
and provide services and others currently focus on commissioning
services only.
Brighton & Hove
— Is an urban area, with a large gay
male population and high HIV rates.
— Brighton & Hove has a centre
of excellence for HIV-related care including a specialist in-patient
unit, a sub-acute HIV care in—patient service, community-based
nursing, psychiatric, psychology and social care teams and additional
voluntary sector input including information, face to face work
including counselling, living well and welfare benefits advice
services, drop-in and structured day care services.
— Brighton & Hove has two universities,
a large number of language schools, and is a major holiday resort
area, all of which helps attract large numbers of young people
to the city, which further increases the transmission of STI's
within the local population.
Activity within GUM/HIV/Contraceptive Services
— The number of contacts in the Brighton
GUM clinic (according to the KC60 returns) has gone up by almost
75 per cent between 1999 and 2001 (from 13,009 to 22,541). Syphilis
diagnoses have risen by 107 per cent from 14 to 29, Gonorrhoea
by 179 per cent from 150 to 419, NSU's from 459 to 1,336, and
Hepatitis by 25 per cent from 92 per cent to 115 per cent.
— The number of HIV+ patients using
the service for regular follow up has risen over the same period
from 476 to 782 (64 per cent) with the number of new diagnoses
continuing to rise from 101 in 1999 (or 8.4 patients per month)
to a projected rise of 156 patients in 2002 (13 patients per month)
54 per cent rise of which 69 per cent are expected to be receiving
combination therapy. HIV testing has risen from 1,606 tests in
1999 to 2,830 tests (76 per cent).
— There is a limited walk-in service
for STIs.
— The current premises are cramped
and no longer ideal.
— No additional recurring funds from
the HIV T&C budget or from HIV Prevention have been allocated
for additional staffing due to financial pressures.
East Sussex
— Two PCTs—Sussex Downs and Weald
and Bexhill and Rother have no GUM/HIV services at all, and Eastbourne
Downs PCT and Hastings and St. Leonards PCT share one full time
HIV/GUM consultant supported by small nursing teams.
— The area is predominantly rural with
a number of large towns.
— There are pockets of deprivation—particularly
in Hastings which also has the highest teenage conception rates
in the county.
— Eastbourne and Hastings have large
populations of young people and is "home" to asylum
seekers and refugee communities who access local services.
— Terence Higgins Trust (South) provides
a drop-in service in Eastbourne and Hastings, specialist acute
in-patient services, and sub-acute services being accessed in
Brighton.
Activity at GUM/HIV/Contraceptive Services
— Contacts at GUM clinics (according
to KC60 returns) have risen from 1,787 in 1999 to 2,803 (57 per
cent) in Eastbourne and from 2,247 in 1999 to 2,998 (33 per cent)
in Hastings.
— HIV testing in Eastbourne has risen
from 221 in 1999 to 337 (53 per cent) in 2001, and in Hastings
from 268 in 1999 to 368 (37 per cent) in 2001.
— The total number of HIV/AIDS contacts
in Eastbourne Clinic has risen from 104 contacts in 1999 to 211
(102 per cent)in 2001 and in Hastings it has risen from 76 contacts
in 1999 to 108 in 2001 (42 per cent).
— Walk-in services are very limited,
with "emergency" care only being offered. Appointments
are generally between two and three weeks for GUM/HIV in both
Eastbourne and Hastings.
— Rise in combination therapy costs
in Eastbourne from c£42k to c£148k over the same period,
and in Hastings in the same period there has been a rise in costs
of c£40k.
— Current premises in both Eastbourne
and Hastings are cramped and no longer ideal.
VIEWS ON THE SEXUAL HEALTH AND HIV STRATEGY
COMMISSIONING SERVICES
(a) Capacity
Existing GUM/HIV/Contraceptive services overloaded
and do not have spare capacity within existing resource constraints
to pick up any additional work generated by the Strategy eg:
— clinical activity (doctor/nursing/health
adviser time—the services in Eastbourne and Hastings are
both part time services, the service in Brighton is overwhelmed
by the massive increase in numbers of people accessing the service).
— premises existing services are cramped
and in inappropriate accommodation, and GP provision will need
to be developed if they are to develop Level 1 services.
— Testing services PHLS/Pathology are
already over-performing on the contract.
— Primary Care little additional capacity
within existing Primary Care services to provide the developments
outlined as a Level 1 service including, IT, and staffing levels.
(b) Training
— To develop capacity within level
1 and level 2 services will require additional training of primary
care practitioners, resulting in an initial reduction in face
to face work with patients whilst training programmes are developed
and implemented.
(c) Funding
— The reworked allocation formula for
HIV treatment and care for the old East Sussex, Brighton &
Hove Health Authority left it some £974k over its deemed
T&C funding target and this funding was reduced in 2001-02
and 2002-03 despite requests for a review of the formula which
disadvantaged both Brighton and Manchester.
— There are year on year additional
costs for combination therapy eg—c£500k in 2000-01,—c£600k
in 2001-02, with a projected rise of £950k for 2002-03.
— Allocations for HIV T&C/HIV Prevention
are based on data collected from GUM/HIV clinics; there is a considerable
time lag between the reporting of increases in incidence of HIV,
numbers going onto to ARV therapy etc and the increase in the
allocations to offset those costs. This results in an expectation
that PCT's/NHS Trusts will have to pick up these costs until the
allocation is increased to meet those ARV costs.
— It should also be noted that individual
PCT's disproportionately affected by large increases in ARV costs
will find it harder to meet those costs, than would a larger health
economy (issues to be resolved here are Lead Consortia arrangements,
shared risk around ARV costs etc).
— Cross charging more than 70 patients
from Brighton & Hove are using in-patient and outpatient services
in London. Each NHS Trust is going to have invoice individual
PCT's for patient care, this will be expensive in staff time,
bureaucratic and slow.
— There is no nationally agreed methodology
for cross charging and this leads to disputes and additional delays
in the system.
— In the short term at least, income
from cross charging will be less than expected whilst host/lead
PCT commissioning arrangements are developed. This will impact
negatively on the monies available for HIV-related services.
— GUM/HIV services are open access
and patients can access services wherever they choose—this
does not sit very comfortably within a cross charging mechanism
which encourages PCTs to ensure that patients only access local
services.
— There needs to be a recognition that
HIV T&C monies have been supporting generic GUM provision,
and altering of such funding streams will have an impact on the
GUM service as well as the HIVT&C services.
(d) Priorities
— It should be noted that PCTs have
been given a whole set of targets/standards/priorities/NSF's to
deliver. It is hard to demonstrate to a PCT that they must pay
attention to a Strategy that does not figure as a "must do"
and doesn't appear in the "Improvement, Expansion and reform—the
next three years" planning guidance in any meaningful way—it
is mentioned on page 20 under "Reducing Health Inequalities",
not as a target but under "National Capacity Assumptions".
(e) Commissioning toolkit
— It should be noted that the Commissioning
Toolkit being developed by the Department of Health will arrive
too late to effect the new PCT Three Year Plans required by February
2003. Likewise the Strategy identifies the role of multi-agency
groups in developing local action plans for PCTs from April 2003
onwards (once the Commissioning Toolkit is available) however
we are being asked to develop our three year plans now—before
the toolkit is available, and in the absence of the Standards
documents.
MAINSTREAMING OF
HIV ALLOCATIONS
— Standards are being developed for
HIV Prevention and Treatment and Care services but are not currently
available. If standards are not in place, and there are cost pressures
on other budgets for PCTs, and in order to achieve financial balance,
then PCTs might be "tempted" to vire monies out of HIV
T&C or HIV Prevention services to off-set costs in "must
do" areas of work.
— Once standards are developed there
is also the potential that there will not be enough money available
to develop "appropriate" services from within the PCT
mainstream allocation and patients may suffer.
— The absence of these standards also
results in an erosion of clarity around what HIV Prevention monies
can be spent on, eg if there are pressures within GUM /HIV/ Contraceptive
services is it legitimate to use Prevention monies to fund additional
Health Advisers/Nurses? This would certainly reduce pressures
in the service initially but could potentially increase HIV transmission
amongst vulnerable groups (if HIV prevention is no longer carried
out) with the associated social and service activity costs.
— Mainstreaming also increases anxiety
amongst service providers who are fully aware of the existing
pressures within PCTs and Sexual Health & HIV related services,
especially with the massive rises in HIV T&C costs.
— This is compounded when there is
also a review of the Aids Support Grant currently taking place,
feedback from the review suggest that the ASG formula will be
"re-worked" and that it will be mainstreamed as part
of the main SSA. This will result in increased scrutiny of this
budget by hard pressed Local Authorities who have specific targets/
activities in relation to children's services, services for older
people, intermediate care etc.
EXPERTISE IN
THE FIELD
— Pre-existing Commissioners of Sexual
Health/HIV services, have now been dispersed across local PCT's,
Public Health Networks, Health Promotion departments etc or have
left the service altogether. A considerable amount of time has
been spent talking to the newly emerging PCTs to raise awareness
of the Sexual Health & HIV Strategy, its impact on existing
services and why it is important to continue to "invest"
in both HIV Prevention and HIV-related services, and in Contraceptive
services.
— Each PCT has to identify a local
"lead" for Sexual Health & HIV—their knowledge
is variable and their workload high, the "lead" is responsible
for developing local action plans with a development group and
feeding into the three year PCT business plans—capacity
and interest in this work is limited, when PCT staff are faced
with conflicting work pressures and priorities.
OPTIONS FOR
CONSIDERATION
— Review the existing allocation formula
methodology to ensure that out of London PCTs receive their "fair
share" allocation.
— Consider the possibility of "bridging
funding" to PCTs to allow them to develop new services in
line with the Strategy in primary care etc whilst allowing them
to continue funding existing services until new services can take
the pressure off GUM/HIV.
— Develop a national methodology for
cross charging with a simple invoicing mechanism.
— Reduce the time lag between rises
in combination therapy costs and the much slower allocation of
additional monies to meet those costs.
— Raise the ring fence on the HIVT&C
and HIV Preventions allocations until:
— The Standards documents are complete.
— The Commissioning toolkit is available.
— The ASG review is complete.
— Clarify the status and priority attached
to the Sexual Health & HIV Strategy for PCTs.
— Develop training programmes co-ordinated
by the Department for local PCT leads in the same way that the
Social Exclusion Unit developed training for local Teenage Pregnancy
co-ordinators to help develop expertise in the field.
— Complete negotiations on the new
GP contract so that work can be progressed at Level 1.
November 2002
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