Select Committee on Health Minutes of Evidence


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.

    —  Relevant background

    —  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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