APPENDIX 37
Memorandum by PACT (SH 57)
FUNDING AND
COMMISSIONING
There are currently approximately 23,000 HIV
positive individuals known to treatment and care services within
the UK. The true cost of their care, including monitoring and
treatment according to BHIVA national guidelines, based on data
from the NPMS-HHC prospective study averages £15,000 per
patient per annum. Thus, the total cost of their treatment and
care in 2002-03 will £345 million.
During 2002-03, a further 2,000 new diagnoses
can be expected. Their additional costs will £30 millions.
This means that the total treatment and care cost will become
£375 millions for 2002-03. This compares with £165 millions
allocated for treatment and care under the previous funding system
for 2001-02. There must be adequate funding for antiretroviral
therapy for all patients; current estimates are that providers
are under-funded by around £3,000-£5,000 per patient
per year after they have presented. Because of the way the figures
are collected we are not funded for our new patients for over
one year. If, as expected, there is a rapid increase in the number
of such patients diagnosed HIV positive because of the targets
set in there may be a funding crisis. There also needs to be standardised
cross-charging and the baseline figures for HIV and AIDS cost
must be accurate.
These costs will be exacerbated by the justifiable
attempts to detect those infected persons that are currently undiagnosed.
For each 1,000 persons newly diagnosed, the additional cost will
be £15 millions for treatment and care alone. The additional
costs of screening in antenatal clinics, GUM clinics and other
settings must also be considered. Other factors that are exacerbating
the cost of care include; the problems associated with the dispersal
of refugees from high prevalence countries, especially to those
parts of the country with lower numbers of HIV patients; and the
difficulties in patient access to GUM clinics, resulting in delays
in diagnosing and treating STIs, not least in the young and in
ethnic minorities
There may be potential difficulties in HIV service
provision because of funding and commissioning pressures that
will put on the providers of HIV care especially now that HIV/AIDS
has gone into the mainstream from April 2002. This was agreed
as a result of the stocktake review in 1997. Unfortunately at
the same time as mainstreaming is being implemented there are
major reorganisations occurring within the NHS. This restructuring
is leading to uncertainty as to how HIV and AIDS money for treatment
and care will be managed. This is resulting in too much time and
effort being spent by providers on reorganising their funding
streams rather than concentrating on service provision especially
as the complex interaction between the strategic health authorities,
PCTs and any continuing specialist commissioning for HIV have
not been made clear.
London, having the highest incidence and prevalence
of HIV and AIDS is, in our opinion, far from ready for the transition
to PCT funded HIV services. In many cases PCTs identified as the
leads for HIV and AIDS are poorly prepared. The strategic health
authorities do not have any financial responsibility for HIV and
AIDS yet in many cases this is where all the commissioning expertise
has been concentrated and a model of working practice is needed
urgently. HIV is an open access service but we are already running
into problems whereby PCTs are considering not transferring monies
to follow these residents who have chosen to have their HIV care
outside of their residence base. Commisioners who have experience
in HIV and AIDS need time to work with the lead PCTs and trusts
to organise mechanisms of communication and make clear the financial
pathways. They can evaluate the risk elements involved and ensure
the transparency of any strategies whereby money has to be transferred
from one PCT to another because of the residence-based funding
of HIV care. Strategic Health Authorities must be clear about
performance management targets for PCTs.
WORKLOAD BROUGHT
ABOUT BY
THE STRATEGY
ON THE
SERVICE
One of the targets of the National Sexual Health
strategy is to increase the number of people who have an HIV test
and ensure that patients who are unaware of their status, become
aware of it. Consequently there will be an increased workload
due to new HIV positive patients attending clinics. It is important
that anyone who is newly diagnosed as HIV positive should have
immediate access to the specialist HIV services, but this will
create pressure on HIV/GUM services. We support this strategic
aim but would recommend an initiative to increase staffing and
improving the physical environment so that the patients can be
seen appropriately. Funding should be available for refurbishment,
new building and manpower
A minimum number of 30 additional (newly funded)
consultant posts is required for each of the next five years in
order to improve service access to acceptable levels. Such numbers
can be supported by the expected numbers of specialist registrars
who will achieve their CCSTs, at least in each of the next two
years. The costs of funding these posts, together with associated
health adviser, nursing, and other clinical support at £120k
per post, will be £3.6 millions in 2002-03.
We should prioritise the need to support consultants
that are currently single-handed. It is also recommended that
each new post should have some sessions within the nearest large
HIV inpatient centre, which will normally be in the nearest teaching
hospital. This will help to attract high calibre individuals to
the more peripheral, often DGH- based clinics, but will also give
further impetus to the development of HIV clinical networks. Work
to develop these networks is essential but progress will inevitably
be delayed unless clinicians are willing and able to work together
with commissioners during the next 18 months. Even at the most
optimistic, it is unlikely that service networks can be operational
before 2005-06. This will be further delayed unless there is appropriate
funding for the national strategy.
ORGANISATION
The ongoing evaluation of the Sexual Health
and HIV strategy will be very dependent on the establishment and
continuing monitoring of standards across the managed clinical
networks. Some scenario modelling examining what clinic management
networks might look like and how they would be co-ordinated would
be useful for those trying to implement the strategy. We support
the work ongoing by the BMA Foundation for AIDS on Service Standards.
As there is no national service framework for
sexual health and GUM, any success of clinical networks will depend
on the over-arching co-ordination and buying-in from Trusts, PCTs
and Regions to maintaining standards and achieve equitable access,
reaching targets and standards of care for each of the networks
established. In order for this to work some of the details regarding
the networks need to be addressed especially from the provider
position. For example, how inpatient beds for HIV should be rationalised,
where specialist HIV care should be located, and maintaining and
endorsement of exiting guidelines and standards of care should
be more clearer.
IMPACT ON
THE SEXUAL
HEALTH SERVICE
Unless adequate funding is forthcoming, and
is appropriately allocated to treatment and care services, there
will either be massive overspending in Trusts, which would cause
a destabilisation of service, or some means of restricting access
to care must be imposed (ie rationing of HIV healthcare). This
is contrary to the principles expressed within the national sexual
health and HIV strategy and will cause a backlash from the groups
representing patients.
The other choice, especially in the majority
of treatment and care services that are provided by GUM clinics,
is to cut staffing and other resources devoted to sexual health
care. The consequence of diverting available resources away from
high volume but relatively low cost patients, in a service that
is experiencing massive increases in patient demand and failing
to provide adequate access, will be detrimental in terms of public
health. Not only will the incidence of HIV inevitably increase,
but also so will other STIs with all of their adverse long-term
health and economic consequences. The fallout at a time when the
Government is trying to launch an imaginative and laudable national
sexual health and HIV strategy is obvious.
CONCLUSION
There must be adequate resourcing (monetary,
manpower and environmental) of HIV services. Standards of care
should be put in place and managed. Clinical Networks should deliver
this care. PCTs and Strategic Health Authorities should be clear
about funding streams in an open-access service. Support for HIV
services should go hand in hand with support for sexual health
services.
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