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.
SERVICES IN PRIMARY CARE
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:
In the strategy we set out a level one, two and
three hierarchy of services, and we envisage many more of certain
of the level one services—the diagnosis, the interview,
the partner chase, all of that—to be done in the primary
care setting.[179]
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 www.doh.gov.uk/shiftingthebalance 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 http://medfash.org.uk/publications. Back
178
Effective Commissioning, p.10 Back
179
Q 1046 Back
180
Commissioning Toolkit, p.14 Back
