HC 1048-III Health CommitteeWritten evidence from Terrence Higgins Trust (PH 122)

1. The public health ring fence will be under considerable strain from the outset and we would welcome more clarification on how this funding will be distributed and what safeguards will be put in place to protect the ring fence.

2. THT would welcome further assurances that the relevant commissioning expertise will be available within local authorities to deliver on sexual health. We would particularly support transferral of existing commissioning expertise from the health service into local authorities, where appropriate, in order to ensure a level of continuity of provision.

3. We would like further clarification of how politicisation of decision making will be guarded against within the new structures for public health commissioning and in particular whether Directors of Public Health will be given sufficient decision making powers and seniority to avoid potential conflicts.

4. Fragmentation of commissioning cannot be allowed to result in divisions in service delivery. There will need to be national leadership in terms of outcomes and minimum service standards, as well as, guidance approaches and best practice. For this reason then we would strongly urge the retention of three proposed HIV and sexual health outcomes.

5. We would welcome further consideration of how and where regional, supra-local or sub national commissioning may be the most appropriate vehicle for delivery and the mechanisms by which this can occur.

6. The level of surveillance that is currently provided by the HPA must be maintained and developed by Public Health England. We would welcome a specific commitment to guarantee the continued provision of:

Specialist and reference services for sexually transmitted infection (STI) microbiology.

Submissions by local services of the range of data required for national surveillance.

7. We would recommend that a stakeholder/patient involvement approach to Public Health is equally important to that applied to NHS service provision and the independence of Health Watch should be prioritised.

1. Introduction

1.1 Terrence Higgins Trust (THT) is the UK’s largest HIV and sexual health charity, with 28 service centres across England. We are a campaigning and membership organisation which advocates on behalf of people living with or affected by HIV or poor sexual health.

1.2 As a service provider we work in a variety of settings and in a range of partnerships. We deliver community based clinical services such as chlamydia screening and rapid HIV testing in areas across England with the aim of augmenting service provision and tackling health inequalities. In addition we also work in various partnerships at local and national level to deliver health promotion and STI prevention campaigns and initiatives which target populations most at risk of HIV and poor sexual health.

1.3 We welcome the Committee’s Enquiry into Public Health and believe that it is timely in terms of the current consideration of the Health and Social Care Bill and the Government’s Listening Exercise on Health Reform. THT has been largely supportive of the proposed direction on Public Health. We welcome the emphasis which the reforms have placed on Public Health as a priority and the commitment to ring fenced funding for its development. There are some areas however, where we would welcome further clarification and we will focus on these in our submission.

2. Public Health Ringfence

2.1 We welcome the ring fencing of the public health budget to discourage short-termism and reductions in health promotion work. Over the last 10 years THT has consistently found evidence, through surveying of clinical staff and commissioners, of money being diverted away from sexual health, to meet deficits in other areas. The current economic climate, and the pressure to identify savings, means that the safeguarding of investment in public health will be essential to securing long term benefits for individuals, communities and the NHS.

2.2 We would however, welcome clarification on how the proposed £4 billion budget will be broken down. Current costs of sexual health services are estimated at around £700–£750 million: potentially between 17% and 20% of the £4 billion budget for public health. The HPA received approximately £240 million in direct Government funding in 2009–10, whilst £514 million is currently spent on central immunisation programmes. These figures represent 6% and 13% of the projected budget respectively. The White Paper also states that the equivalent of 15% of the QOF will be devoted to Public Health and will be managed through the Public Health England budget. We have heard cost estimates of £1 billion for the QOF, requiring a potential £150,000, or 4% of the public health spend.

2.3 Public Health England will also be subject to running cost reductions and efficiency savings, and set up and restructuring costs could be significant. This comes against a backdrop of significant budget reductions for local government over the next five years. This means that the public health ring fence will be under considerable strain from the outset and we would welcome more clarification on how this funding will be distributed and what safeguards will be put in place to protect the ring fence.

2.4 Whilst we are very much in favour of greater integration of services between areas such as health, social care and education, we are concerned that the current financial situation of local authorities could mean that they could be tempted to categorise a wider range of services under the banner of public health to ensure a more sustained source of funding. We are concerned that the definition of what constitutes public health should not be so broad as to create compete permeation of the ring fence. We would hope that Health and Wellbeing Boards will be required to ensure that the public health ring fence is being used appropriately and that services such as health protection requirements that are already commissioned via the block grant to local authorities are not considered within the remit of the public health ring fence.

3. Commissioning Routes for HIV and sexual health

3.1 The proposals for HIV and sexual health service commissioning outlined in the White Paper and accompanying document detail a number of new routes for the development and funding of services. We are concerned that these proposals could amount to a significant fragmentation of services with HIV services being commissioned nationally, potentially by the National Commissioning Board; specialist sexual health services provided by local authorities, community contraception provided by GPs, funded via the GP contract and national prevention initiatives potentially provided via Public Health England.

3.2 Fragmentation of commissioning cannot be allowed to result in divisions in service delivery. At the very least there will need to be national leadership in terms of outcomes and minimum service standards, as well as, guidance on effective approaches and best practice. For this reason then we are strongly urging the retention of three proposed HIV and sexual health outcomes on:

The under 18 conception rate.

Chlamydia diagnosis rates per 100,000 young adults aged 15–24.

Proportion of persons presenting with HIV at a late stage of infection.

4. Role of Local Authorities

4.1 The reforms outlined in the White Paper propose that integrated sexual health services should come under the remit of local authorities in their new public health role. There is a rational argument that local authorities can make a success of this commissioning as many of the determinants of poor sexual health fall within their remit, for example, social deprivation and sex and relationships education. As such, we are optimistic about the transfer of public health responsibilities to local authorities.

4.2 We are concerned, however, that it has been a number of decades since local authorities have taken the lead on sexual health and in recent times it has been difficult to get some authorities to meaningfully engage on the issue. We would welcome further assurances that the relevant commissioning expertise will be available within this structure. We would particularly support transferral of existing commissioning expertise from the health service into local authorities where appropriate in order to ensure some continuity of provision. It is also essential that accountability mechanisms are in place to guarantee service quality and consistent standards of care.

4.3 The provision of comprehensive and effective sexual health services, including access to abortion, HIV prevention and contraception, is essential for wider public health and cannot be compromised by political processes. Some of this work can be potentially controversial, for example: providing HIV prevention outreach in public sex environments. We believe that decisions on these issues must be made on the basis of public health benefit and not be influenced by political concerns. For this reason then, we would like further clarification of how this will be guarded against within the new structures for Health and Wellbeing Boards, given the potential role of elected representatives on those Boards. In particular, we would welcome a clear indication as to whether the Directors of Public Health will be given sufficient decision making powers and seniority to avoid these problems.

4.4 We support the ADPH’s call for Directors of Public Health to be accountable directly to the Chief Executive of the Local Authority, be jointly appointed by Public Health England, and have direct access to councillors.

5. HIV Specialist Services

5.1 Currently specialist HIV services are commissioned via PCTs. These services provide clinical care and treatment to people living with HIV and are frequently hospital based services. They can be stand-alone HIV clinics or co-located within Genito-urinary Medicine (Sexual Health clinics) or Infectious Diseases Units.

5.2 The Public Health White paper outlines plans for these services to be commissioned nationally. This could work to drive up standards of care and the development of centres of excellence. It also avoids handing commissioning to GPs who can be inexperienced in dealing with HIV.

5.3 However, this arrangement does not fully address the need for greater GP and primary care involvement in the provision of HIV patient care. The current model of care is highly specialist and centralised within PCTs. Whilst GPs may generally lack confidence or knowledge on HIV, there is a need to develop their skills and include them more in the delivery of simple aspects of HIV monitoring and care. Over centralisation of services can have serious implications, both in terms of costs to the NHS and in bringing care and self management processes closer to the patient.

5.4 Whilst the proposals for Public Health do not prohibit regional working, there is a lack of detail available on what regional, supra local or sub-national commissioning arrangements could or will look like. For some conditions, regional, or supra-local, commissioning arrangements will be the best means by which to provide services. HIV has only recently been removed from the National Definitions Set and it is therefore likely that commissioning, using regional lead consortia will be most effective way to manage the provision of HIV services. However, we are not clear if this is an option that will be given consideration in the reform process.

5.5 This model would provide a greater balance in terms of securing the benefits of increased local delivery of care and activity with the need to ensure knowledgeable and informed commissioning. The low volume/ high cost nature of HIV interventions means that a regional lead approach will also be necessary in order to manage financial risk.

5.6 The proposed new structure will also result in a more complicated arrangement for commissioning HIV services provided from Genito-urinary Medicine. These types of co-located services can provide continuity of care and service provision by bringing together testing, diagnosis, care and partner notification services. Under the proposed structure, Local Authorities will now be responsible for commissioning of the sexual health element, including HIV testing, but the National Commissioning Board could possibly commission the HIV treatment and care element.

6. HIV Prevention and Testing

6.1 Local HIV prevention work and campaigns will be commissioned by local authorities with additional national campaigns work overseen by Public Health England. This does create an issue around the possible fragmentation of prevention working; between HIV treatment commissioned nationally, potentially by the Commissioning Board, prevention and testing work commissioned by local authorities, and national campaigns overseen by Public Health England.

6.2 Whilst the Public Health White Paper does allow for the pooling of budgets and cross border working, established PCT arrangements will need to be dismantled and, even with successful reorganisation, there is a real risk that momentum could be lost. Currently successful cross border commissioning arrangements have been established and developed between PCTs such as the South London HIV Partnership. There is therefore a risk of reverting to duplication of working, lower quality campaigns and higher eventual costs for local authorities.

7. Surveillance and Epidemiology

7.1 We understand that Public Health England will absorb many of the functions currently delivered by the Health Protection Agency. From an HIV and sexual health perspective the surveillance provided by the HPA provides a crucial tool for the development of effective approaches to HIV and STI prevention and detection. The HPAs surveillance in this area is amongst the best in the world and we would encourage the Government to ensure that this quality is safeguarded and indeed built upon in the movement to Public Health England. Quality surveillance and research will also be crucial to the Government’s aim to move towards an outcomes based assessment of health services.

7.2 We believe that the proposed structure can work successfully. However, the level of surveillance that is currently provided must be maintained and developed. It will also be essential that the advice and information provided by the agency maintains a strong level of independence. We would welcome a specific commitment to guarantee the continued provision of:

Specialist and reference services for sexually transmitted infection (STI) microbiology. The expertise for these is not found in NHS laboratories at local level meaning that the functions of the Sexually Transmitted Bacteria Reference Laboratory (STBRL) must be retained within Public Health England.

Submissions by local services of the range of data required for national surveillance, in order to ensure public health strategic planning is informed by current evidence of need.

8. Accountability and Patient Involvement

8.1 We are unclear about the role which GP consortia will play locally with regards to Public Health provision. We would welcome capacity for decision making within Health and Wellbeing Boards which requires GP consortia to assist with arranged areas of work. Currently Consortia are only required to ‘have regard’ for the priorities of Health and Wellbeing Boards. If we are to secure greater integration in service provision, then Consortia must have a duty to meaningfully engage with Health and Wellbeing Boards.

8.2 We continue to have some concerns about the profile of patient participation within the plans for Public Health. The move to localism brings the potential for a range of improvements. However, without significant mechanisms for patient and stakeholder involvement there is a risk that services will be determined locally on the basis of how visible groups are. We are particularly concerned about this from the perspective of groups of people within communities who are at increased risk of HIV. These groups are most commonly comprised of gay men and people of African origin who are potentially less likely to be vocal within communities.

8.3 We are concerned that local Health Watches will be hosted by Local Authorities. Given that Local Authorities will have Public Health responsibilities we believe that this may result in a conflict of interest and could compromise local accountability in terms of Public Health functions.

June 2011

Prepared 28th November 2011