Health and Social Care Bill

Memorandum submitted by the Faculty of Sexual and Reproductive Healthcare and the British Association for Sexual Health and HIV (HSR 38)

1.0 The need for a national tariff in Genito-Urinary Medicine (GUM) and Sexual and Reproductive Health (SRH) Services

1.1 This briefing note has been written for members of the Health and Social Care Bill Committee, in advance of the debate on the clauses in relation to Clause 114 on ‘ Pricing’ of the Health and Social Care Bill, scheduled to be debated on Tuesday 12th July.

1.2 The briefing makes the case for a national tariff in GUM and SRH to protect high quality services, encourage prevention work alongside clinical care, improve outcomes, realise cost savings and integrate care [1] .

2.0 The role of tariff in public health

2.1 On 22nd March, Health Minister Simon Burns tabled the following amendment :

"I beg to move amendment 400, in clause 104, page 95, line 21, leave out from first ‘the’ to end of line 23 and insert:  ‘public health functions of the Secretary of State, or of a local authority, under the National Health Service Act 2006.’.

"The amendment makes it clear that the national tariff cannot cover public health services, which are the responsibility of the Secretary of State and local authorities, rather than of Monitor and the NHS commissioning board. Committee members will note that nothing in the Bill will stop the Department of Health from seeking advice from Monitor on public health pricing, but services commissioned by the Department and local authorities will not be subject to the national tariff [2] ." 

2.2 Any Qualified Provider (AQP) will be introduced to community services from April 2012 and, in order to prevent price competition, will be restricted to services with national or locally set "tariff" prices. Currently very little community work is covered by a tariff and given the diversity of community services and the scale of challenge in developing comprehensive national tariffs the Department of Health has stated "we will be heavily reliant on local price setting (tariff) for the initial implementation of choice of any qualified provider".

2.3 It is a complex process to develop a tariff and clearly the Department of Health would not be able to develop a national tariff for all aspects of community services in time for the April 2012 introduction of AQP in community services.

2.4 However there has been a national tariff in GUM for some time and extensive work has recently gone into developing an integrated tariff for GUM and SRH by the London Sexual Health Programme on behalf of the London Primary Care Trusts.

2.5 Given the development of tariffs in GU and SRH, we are asking that the committee re-consider Clause 114 and make provision for national tariff to cover public health services where appropriate or where a tariff has been developed, as is the case in GU and SRH.

3.0 Ensuring high ‘quality’ community services the same level of protection as other NHS services.

3.1 As stated above, there can be limitations to developing national tariffs in community services, but where a community tariff can, or has, been developed such as in SRH and GUM then it should be applied nationally to:

· Ensure competition is on quality, not on an arbitrary ‘local price’

· Reduce the risk of variations in price

· Guard against providers being able to ‘cherry-pick’

· Protect high quality community services in the same manner as other NHS services.

10 reasons for a national tariff for GUM and SRH

The Sexual Health tariff will be a set of payments that reflect the cost of the providing the care. Payments are based on clinical pathways (about 150 of them) that cover the broad range of work carried out in SRH and GUM clinics.

4.1 The tariff will help equal out payments so that they actually reflect the level of service provided and type of treatment given. This will mean that sexual health services reflect aspirations set out in the White Paper where, "money will follow the patient through transparent, comprehensive and stable payment systems across the NHS to promote high quality care, drive efficiency, support patient choice."

4.2 The tariff will support the drive to integrate SRH and GUM services which offers efficiencies and is a central aim of the Health and Social Care Reform Bill.

4.3 A large proportion of sexual health service delivery focuses on the prevention of sexual ill health (STI screening, Chlamydia screening programme) and the prevention of unplanned pregnancy. Ensuring these pathways are priced accurately, via a tariff, allows for a whole range of effective health promotion and prevention activities to be delivered alongside clinical care.

4.4 A tariff is key to ensuring that future GUM and SRH services are appropriately remunerated for the important public health work that they do and they are intended to drive good practice and increase access to sexual health services.

4.5 The tariff would allow for a direct link to be made between outcomes and payment. They are based on best-practice pathways and should deliver the highest standard of care.

4.6 A tariff allows for the development of prices that are setting-independent and could be used by a variety of providers.

4.7 A localised tariff price would not be applicable in sexual health, because patients do not necessarily respect health authority borders.

4.8 A localised tariff price would not be appropriate in sexual health because providers should be paid the same regardless of where the patient comes from.

4.9 Extensive time and resource was invested in developing an integrated tariff for GUM and SRH by the London Sexual Health Programme on behalf of the London Primary Care Trusts. It is unlikely that new Directors of Public Health will be able to replicate that work, and it would be an unnecessary use of resources for each of them to spend time 'reinventing the wheel'.

4.10 National tariffs, by guaranteeing an adequate funding stream, will also help to protect the sexual health proportion of the ringfenced budget being used for other services provided by local authorities.

5.0 About Sexual Health Services

5.1 Sexual health services incorporate a wide range of care activities predominantly covering the management of sexually transmitted infections and the provision of contraception. These activities range from the very basic (provision of condoms) to the very complex (management of tertiary syphilis or medical gynaecology in the community). A range of different service delivery models are in existence which generally fall into three groupings:

5.2 Genito Urinary Medicine (GUM) – services that manage sexually transmitted infection and HIV. Currently funded by a national tariff.

5.3 Sexual and reproductive health (SRH) – services providing contraception and reproductive healthcare. Largely funded under block contracts

5.4 Integrated Sexual Health (ISH) – services providing both GUM and SRH and often with mixed funding arrangements

· At present GUM services are paid a flat rate for each visit to their clinics, however this is still a nationally agreed tariff.

· SRH services are paid by block contracts - that is they are paid a lump sum for the totality of their work. This means that SRH services aren’t always paid for the work that they actually do, it also makes service development to meet public health need difficult.

· A tariff for HIV is currently under development, and HIV will be commissioned nationally by the National Commissioning Board and therefore does not sit within the purview of public health.

6.0 The Faculty of Sexual and Reproductive Healthcare

6.1 The Faculty of Sexual & Reproductive Healthcare (The Faculty) is a faculty of the Royal College of Obstetricians and Gynaecologists and is the leading body representing the interests of doctors involved in sexual and reproductive healthcare. The Faculty has a membership of over 15,000, the majority of whom are GPs, the remainder being doctors working in the community in Sexual & Reproductive Healthcare. In early 2010 the Government established the new medical specialty of ‘Community Sexual and Reproductive Health’, to formalise the training of community based specialists in women’s health with a leadership role and relevant of public health training. The Faculty sets National clinical and service standards and awards competency based qualifications to specialists and GPs in the field of Sexual & Reproductive healthcare (SRH) which includes contraception, basic management of sexually transmitted infections, community gynaecological care.

The British Association for Sexual Health and HIV

6.2 The British Association for Sexual Health and HIV - BASHH - was formed in 2003 through the merger of the Medical Society for the Study of Venereal Diseases (MSSVD; established 1922) and the Association for Genitourinary Medicine (AGUM; established 1992). The Association’s membership of 700 includes medical practitioners, scientists in the field of medicine and other healthcare workers who have shown a commitment to the GU specialty. The objectives of BASHH are:

· To promote, encourage and improved the study and practice of the art and science of diagnosing and treating sexually transmitted diseases including all sexually transmitted infections, HIV and other sexual health problems.

· To advance public health so far as it is affected by sexually transmitted diseases and to promote and encourage the study of the public aspects of sexually transmitted diseases including all sexually transmitted infections, HIV and other sexual health problems.

· To advance the education of the public in all matters concerning the medical specialty of Genitourinary Medicine, to include the management of HIV infections and the broader aspects of sexual health.

· To promote a high standard in the medical specialty of Genitourinary Medicine to include the management of HIV infections and the broader aspects of sexual health.

July 2011

[1] It should be noted that HIV care will be commissioned by the National Commissioning Board, for which a national tariff is being developed. This briefing is therefore solely focussed on recommending how GUM and SRH services can be fairly remunerated for all other STI and Reproductive Healthcare services.


Prepared 19th July 2011