Select Committee on Health Third Report


The impact of the Strategy on the organisation of service delivery: general issues

Commissioning of services

179. The thrust of the Strategy is that far more services will be devolved to primary care, either to individual practices, or groups with specialist skills, or managed networks. Very few of those submitting evidence welcomed this unreservedly. Anne Edwards, a clinical director of GUM Oxford, described a local audit of the outcome against national guidelines for 100 patients diagnosed with chlamydial infection outside GU medicine (ie in primary care or family planning). Of those seen for follow up in GU medicine, 80% required re-treating, which Ms Edwards suggested indicated the difficulties of managing STIs effectively in non-specialist settings.[167] King's College NHS Trust, which we visited, saw some potential benefits in the management of HIV patients in primary care, but remarked that their clinic was attended by patients who had telephoned local practices having been told there was a two to three week wait for a GP appointment.

180. The additional constraints of confidentiality associated with sexually transmitted diseases was another commonly expressed cause for concern. The Herpes Virus Association suggested that the provision of services at primary level would be inappropriate since "many patients fear that they could be recognized by others when they attend the STI session or that the STI clinic records might be accessed by others in the health centre."[168]

181. The National AIDS Trust saw no signs of the development of commissioning via consortia and felt that the new model of working might easily lead to fragmentation of services.[169] When we visited Manchester, we were told that three separate PCTs were responsible for 'leading' on sexual health.

182. Following the NHS reforms introduced by Shifting the Balance of Power, responsibility for commissioning of sexual health treatment and care was devolved to PCTs.[170] Owing to the stigma attached to sexual health issues, many people who seek access to sexual health services do so outside their own area of residence. This creates difficulty in terms of PCT commissioning and service provision. In June 2002 we asked Department of Health officials how PCTs would be reimbursed for treating patients resident in other areas. At that time we were told that there was no definitive answer to our question.[171] In January 2003 we asked Public Health Minister this same question. Her reply was:

    It is obviously for PCTs themselves to sort out a mechanism for how they are going to reimburse each other for treatments provided ... every PCT is responsible for the cost to its residents so there needs to be a local mechanism agreed as to how those costs can be apportioned ... It is not a matter for the centre to dictate how they should do that but we will be giving them support to enable them to get robust mechanisms in place.[172]

183. The Department recommends that PCTs use networks and consortia arrangements in order to plan and purchase sexual health services. The Department asked each PCT to identify a sexual health lead person who would oversee the commissioning process.

184. We note the findings of a research report produced in December 2002 by the British HIV Association, the National Association of NHS Providers of AIDS Care and Treatment (PACT) and the Terrence Higgins Trust. Disturbing Symptoms concluded that many PCTs have been unable to implement the work needed to respond to the rising rates of HIV and other STIs, that sexual health services do not have the resources they need to implement Government policy, and that: "there is a level of dislocation of views between those commissioning services and those providing them."[173]

185. The survey found that one in four of the PCTs which responded have not included sexual health and HIV in their Service and Financial Frameworks, and registered concern that PCTs might restrict open-access GUM services by only paying for services provided locally. In response to these findings, the Public Health Minister told us that "significant progress" had been made since the survey had been carried out. She reported that 286 PCTs now had sexual health leads and that there were currently "only eighteen outstanding".[174]

186. Many of the sexual health service providers who spoke to us emphasised the importance of networks and consortia working in terms of service provision, and went on to call for commissioners to participate in these networks. Ruth Lowbury, of MEDFASH was one such service provider:

    it is very important for networks to be set up in such a way that there is an identified lead person, so that somebody has the responsibility for taking it forward, so that commissioners can play a key role, either in terms of leading the network, or ensuring that the network lead is there ... Resources are needed, maybe not major resources, but enough to allow people to get together to get the time to work it out, to get the time to attend meetings.[175]

187. Ms Lowbury's evidence gives some indication of the pressure exerted on service providers in terms of time and resources, as they seek to fulfil their clinical commitments and also to develop and maintain networks.

188. We recommend that commissioners participate in sexual health service networks, and that they should be accountable to service providers through transparent commissioning processes. Consortia are essential to the establishment of comprehensive service networks, particularly in rural areas. We believe that the Department must require Strategic Health Authorities to ensure that preliminary development of consortia is taking place, based on regional commissioning groups such as are in place for cancer services, so as to give a definite impetus to the development of networks.

189. The Department has issued a Commissioning Toolkit for commissioners in PCTs and local authorities, as recommended best practice guidance for sexual health services.[176] The Department has also commissioned work to develop and publish standards for service delivery across a broad range of sexual health treatment and care services (including partner notification).[177] The Toolkit states that primary care-led commissioning is now where "influence on the direction, quality and quantity of sexual health provision will be determined."[178]

190. We welcome the guidance provided by the Department of Health in issuing the Commissioning Toolkit and also recommend that the standards developed by MEDFASH and The Specialty Societies in Genito-urinary medicine should be used by Strategic Health Authorities in managing the performance of trusts.

191. We remain concerned that patient choice with regard to HIV and sexual health services will be limited should PCTs decide against paying for patients to use services outside the PCT area. We recommend that the Government, after consultation with commissioners and service providers, should issue further guidance and ensure funding arrangements which enable patients to access sexual health services away from their home PCT area if they wish, in line with the recommendations of the Monks Report.


192. Together with Shifting the Balance of Power, the National Strategy for Sexual Health and HIV also promotes devolution of some aspects of sexual health service delivery to primary care. The Public Health Minister told us:

193. The Commissioning Toolkit includes a section on improving support to primary care in its recommended checklists for commissioning. This contains a provision that the views of GPs should be taken into account on the introduction of a shared care scheme. However, while primary care, and General Practice in particular, might be a setting conducive to effective screening and management of long term conditions, sexual health has not hitherto been a priority for primary care and in some areas primary care may lack the specialist expertise needed to deliver sexual health services.

194. The Commissioning Toolkit states that: "Anonymity and confidentiality are key indicators for successful access and uptake of services, and for respecting people's rights to dignity and privacy."[180] However, confidentiality in General Practice remains a worry for many patients with sexual health problems, and particularly with regard to HIV testing.

195. We recognise that the delivery of some sexual health services through primary care has considerable potential in terms of access and continuity of care. However, we have not been assured that General Practitioners will receive sufficient training and support to deliver services effectively, nor that PCTs will provide sufficient encouragement to GPs to offer improved sexual health services. These may be matters which could be addressed through the new GP contract.

167   Ev 321 Back

168   Ev 163 Back

169   Ev 89 Back

170   See Back

171   Qq 88-89 Back

172   Q 1097 Back

173   BHIVA, PACT, Terence Higgins Trust,. Disturbing Symptoms: how Primary Care Trusts are responding to the challenges of sexual health and HIV, and how specialist clinicians view the resulting changes, Terence Higgins Trust, 2002, p 2 Back

174   Q 1093 Back

175   Qq 701-2 Back

176   Department of Health, Effective commissioning of sexual health and HIV services: a sexual health and HIV Commissioning Toolkit for Primary Care Trusts and Local Authorities, January, 2003 Back

177   MEDFASH has been commissioned by the Department to develop recommended standards for sexual health services and to facilitate the development of sexual health networks.MEDFASH has already developed new standards for NHS HIV services, which are available to download.These standards will soon be finalised and published. See Back

178   Effective Commissioning, p.10 Back

179   Q 1046 Back

180   Commissioning Toolkit, p.14 Back

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Prepared 11 June 2003