Young people's sexual health: the National Chlamydia Screening Programme - Public Accounts Committee Contents

1 Achieving cost effective delivery in a devolved healthcare system

1.  The National Chlamydia Screening Programme is a major Department of Health initiative, launched in 2003, which aims to identify the sexually transmitted infection (STI) Chlamydia trachomatis ('chlamydia'), treat those infected and reduce transmission to others.[2] Chlamydia is the most common bacterial STI and is increasing in young people under 25. Between 2004 and 2008 the number of young people diagnosed with chlamydia in genito-urinary medicine clinics rose by 14%, to more than 71,000. The infection can be easily identified and treated, but if left untreated may cause severe health complications including pelvic inflammatory disease, ectopic pregnancy and infertility in women.[3] The probability of chlamydia infection leading to complications is not well understood.[4] In November 2005 the Department appointed the Health Protection Agency to oversee the Programme which is delivered locally by the 152 Primary Care Trusts (PCTs) in England.[5]

2.  The Department does not know how much money PCTs have spent on delivering testing and therefore cannot tell whether the Programme represents value for money.[6] The Department allocated £150 million for the Programme to PCTs between 2003 and 2009, but only £100 million is estimated to have actually been spent on delivering the Programme.[7] The Department explained that many PCTs were facing financial deficits between 2005-06 and 2007-08 and that the money had been spent on other priorities, but accepted that it had no way of tracing what these had been.[8] An estimated £42 million was spent on the Programme in 2008-09, however, PCTs engaged more energetically with the Programme after chlamydia testing was made a national priority.[9]

3.  The Programme is an example of the difficulties which can arise when a national initiative is introduced into a locally-managed NHS when influences and incentives for PCTs are not adequately addressed from the beginning and all aspects are locally commissioned, regardless of economies of scale. There has been duplication of effort and cost in several aspects of the Programme and the Department accepted that lessons should be learnt from the Programme, in particular the need to be very clear about what should be done at national, regional and local level.[10] Recent reports by the Committee, including end-of-life care, tackling alcohol harm, and autism, have provided evidence that PCTs often do not have a good sense of what local need actually is, are not yet good at commissioning and do not have the information to recognise the costs and benefits of different services.[11]

4.  The costs of delivering a chlamydia test under the Programme are highly variable between PCTs, indicating that there is scope for efficiency savings. Savings of £40 million per year could be made from 2010-11 if every PCT delivered tests for £33, which the Agency estimates is achievable.[12] The Department accepted that the variations in cost were unacceptable and committed to provide PCTs with a costing model, based on work conducted by the National Audit Office and the Agency, to break down their costs more easily and to benchmark themselves against the kind of price shown in the model.[13] The Department had produced guidelines on costs when the Programme started to be rolled out nationally in 2005, but it accepted that there was now evidence of large cost variations which needed to be tackled.[14]

5.  Following its launch in 2003, the Programme was rolled out in three successive phases. All PCTs were commissioning chlamydia testing under the Programme by March 2008.[15] The phased delivery of the Programme could have been beneficial if lessons had been learnt along the way, however this only started to happen some ten years after a screening programme had been recommended by the Chief Medical Officer's report.[16] This meant that when PCTs increased their activity in response to the Department's introduction of a target in April 2008, inefficiencies in the Programme were multiplied, making it even more wasteful of taxpayers' money.[17]

6.  Fragmented local purchasing led to a broad range of prices being paid for equipment and services. Local areas paid between 50 pence and £44 per test kit purchased in 2008-09, and each local area developed its own IT system for the Programme with prices varying from £1,000 to £100,000.[18] There was an opportunity to secure economies of scale by bulk purchasing standard items for the Programme, but the Department failed to put in place any national or regional procurement arrangements and as a result money was wasted.[19] The Department is now setting up regional procurement hubs for the NHS and committed to make dramatic improvements in procurement and IT for the Programme.[20]

7.  PCTs acting individually also procure services which support the Programme, such as marketing activities to encourage young people to get tested, and websites which allow them to order testing kits through the post. This has contributed to 45 different local 'brand identities' being developed for the Programme.[21] The Committee heard evidence of a company which had approached the Department and the Agency two years previously, offering to provide a national website to allow young people to order tests through the post, but was told to approach the 152 PCTs individually. The Department acknowledged that a report on the Programme conducted on its behalf by Dr Ruth Hussey and issued in November 2009 had recommended that a national website should be established. The Department said it would look at this very seriously.[22]

8.  The Department has not defined by how much or by when the Programme should reduce the prevalence of chlamydia.[23] A model developed by the Agency in 2006 indicated that testing 26-43% of the 16-24 year old population could be expected to produce a substantial reduction in the prevalence of chlamydia infection. Taking into account all chlamydia testing under the Programme and in genito-urinary clinics, an estimated 24% of young people were tested in 2008-09, approaching the level where the Programme's impact could be measurable.[24] However, the Department currently has no means to measure the Programme's impact[25] and needs to do so in order to gain an understanding of the cost-effectiveness of the Programme.[26] The Agency has developed a proposal for a population-based survey to monitor changes in chlamydia prevalence and is seeking funding to implement this.[27]

9.  Unless young people are provided with advice on safer sex and how to prevent infection when they are tested, any reductions in the level of chlamydia infection will only be sustained through continued high levels of testing and treatment, which may not be cost-effective.[28] The Department acknowledged that it is vital that the Programme is used to deliver advice to young people, pointing out that this was a difficult client group to deliver such messages to.[29]

10.  In 2008-09, 88% of people who tested positive for chlamydia were recorded as having received treatment, against the Programme's standard of 95%. This means that an estimated 6,480 people who tested positive for chlamydia were not recorded as having received treatment. Without treatment, testing is wasted for the individuals concerned, since these people remain infected and may go on to infect others.[30] The Agency acknowledged that it should aim to treat all people who test positive, but said that over the life of the Programme an average of 90% of people identified as positive had been treated and that considering the difficulties in reaching young people with this type of Programme, this was not a bad outcome. The Agency had looked at the PCTs with the lowest treatment rates and considered that the predominant reason was one of reporting treatment data to the Programme rather than problems in getting people treated.[31]

11.  Most areas are not achieving the Programme's standards for tracing and treating the sexual partners of people who test positive. In 2008-09, nearly three-quarters of programme areas (72%) failed to meet the Programme's recommended standards for partner treatment.[32] Partners are very likely to be infected and failure to trace and treat them means that the infection will continue to spread.[33] However, genito-urinary medicine clinics, which are outside the Programme, also do not meet recommended standards for tracing and treating partners. The Department acknowledged that some areas needed to improve but said that contacting and treating partners of infected people was a challenging area and that levels of partner treatment were higher than those initially predicted by the Agency.[34]

2   C&AG's Report, para 1 Back

3   C&AG's Report, para 1.1 Back

4   C&AG's Report, para 2.8 Back

5   C&AG's Report, paras 1.10 and 2 Back

6   Qq 40 and 41 Back

7   C&AG's Report, para 3.7 Back

8   Qq 60-64 Back

9   C&AG's Report, paras 1.2 and 2.9 Back

10   Qq 30 and 53; C&AG's Report, para 10 Back

11   Qq 9 and 54 Back

12   C&AG's Report, para 3.8 Back

13   Qq 39-41 Back

14   Q 11 Back

15   C&AG's Report, para 1.8 Back

16   Qq 10 and 11 Back

17   Q 87 Back

18   Q 24; C&AG's Report, para 3.10 Back

19   Qq 20-31 Back

20   Qq 19-31 Back

21   Q 45; C&AG's Report, para 3.11 Back

22   Qq 27 and 34-37 Back

23   C&AG's Report, Recommendation a(i) Back

24   C&AG's Report, para 2.5 Back

25   C&AG's Report, para 2.5 Back

26   Q 82 Back

27   C&AG's Report, para 2.5 Back

28   C&AG's Report, para 2.19, Recommendation b(ii) Back

29   Qq 14 and 15 Back

30   C&AG's Report, para 2.12 Back

31   Qq 48, 49 and 68-72 Back

32   A programme area may include more than one Primary Care Trust. There are 91 programme areas and 152 Primary Care Trusts in England. Back

33   C&AG's Report, para 2.13 Back

34   Qq 65-67 Back

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