HC 1048-III Health CommitteeWritten evidence from the British Association for Sexual Health and HIV (PH 175)

Executive Summary/Key Points

In recent years, sexual health has been recognised as a public health priority, and with centrally funded support, sexual health services have become an NHS success story. Services have embraced significant changes in work practices and developed new and innovative approaches to patient care. It is vital that the commissioning infrastructure builds on these successes and continues to enable high quality sexual health services that are not only efficient, but put patients first and deliver real and tangible health outcomes. However, continued success depends on continued investment. Historical experience shows that under budgetary pressures, sexual health services are often the first to get cut and therefore, robust measures must be put in place to ensure that the ring fenced public health budget remains truly ring fenced.

BASHH welcomes the inclusion of “open access” sexual health services within the remit of the public health ring fenced budget as it demonstrates a proactive move to improve sexual health and reduce health inequalities through a unified public health approach.

Whilst BASHH welcomes “outcomes” as far as they promote improvements in public health, we are concerned about adverse consequences related to the wholesale removal of process targets, including the 48-hour access target for sexual health. Unlike other areas of public health, STIs and HIV are transmissible, but also avoidable, and therefore rapid open access to sexual health services is vital for early detection, reduction in onward transmission, reduction in adverse consequences related to late diagnosis and for delivering cost savings associated with the delivery of high quality sexual health care. Requirements must be put in place to ensure all services are rapid open access.

BASHH is concerned that increased competition between providers may lead to a “race to the bottom” competition on price rather than quality, and this concern is exacerbated by the fact that according to the health reforms, that national tariff will not apply to public health services. Tariffs for sexual health are a vital element of the QIPP agenda, ensuring that services provide value for money, are affordable, do not destabilise services/providers or PCTs, are in the best interest of patients and public health, and promote the integration of services. The London Sexual health Programme has developed an integrated tariff for sexual health: BASHH recommends that this tariff applied across all sexual health services as part of the QIPP agenda.

Under increased competition, BASHH welcomes the principle of the “any qualified provider” rather than the “any willing provider” approach to commissioning in so far as it ensures that only sexual health services which are underpinned by nationally recognised quality, clinical and training standards, are commissioned. This will ensure the delivery of high quality care, which is clinically effective, safe, and cost efficient.

BASHH is concerned that Local Authorities may not have the correct skills or expertise to commission specialist clinical services such as those for sexual health. It is only by ensuring that commissioning service specifications are underpinned by nationally recognised clinical and quality standards, commissioning decisions are based on comprehensive public health data and evidence, and that sexual health clinicians are engaged in the commissioning process that the highest quality of sexual health care will be provided.

Whilst BASHH welcomes the commitment to health protection through the proposed continuation of the functions of the HPA, and hopes the new service may encourage further opportunities for research and data analysis, BASHH is concerned that the move may threaten the independence, credibility and trust of the service, and recommends that measures are put in place to ensure any credibility is not lost.

The UK has one of the worst rates of STIs in Western Europe, and therefore, excellent leadership in sexual health is vital to ensure that we meet the challenges that face the health services both now and in the future, and to ensure that there are recognised clinical and training standards in place to enable the delivery high quality sexual healthcare at the local level. BASHH is concerned that, unless incentivised, non NHS providers will not provide training in sexual health, which could lead to a reduction in quality of patient care. It is vital that non NHS providers are subject to the same requirements with regards to education, training, as those working in the NHS, and that such training meets nationally recognised standards.

Arrangements for Commissioning Public Health Services

1. BASHH welcomes the inclusion of open access sexual health services provided by sexual health services within the public health service. Open access sexual health services are available to all regardless of PCT of residence and, therefore, ensuring their continuation under the new public health service demonstrates a proactive move to improve the sexual health of our population through a unified public health approach.

2. Investing in high quality, rapid open access sexual health services produces longer-term savings as early detection and treatment of STIs, along with partner notification, reduces onward transmission and reduces adverse consequences such as ectopic pregnancy and infertility. An emphasis on increased HIV testing will also help identify the one in four people who are unaware of their condition and one in two who present with a late diagnosis. Poor sexual health is more common amongst people who already experience inequality associated with their age, gender, ethnicity, sexuality or economic status, and poor sexual health also affects a significant number of people who have other public health needs, in particular alcohol and drug misuse and violence. It is often these most deprived and marginalised communities that find it hard to access health services. Therefore, for the social, health and economic benefits it brings, ring-fenced funding of sexual health services and sexual health promotion via Public Health England is an “invest to save” concept.

3. Commissioning sexual health services as part of the ring fenced public health budget will help ensure that fully comprehensive, rapid open access sexual health services are delivered across a range of health and community settings, and in particular, reach communities vulnerable to or at risk of poor sexual health, therefore delivering the best possible outcomes for the local population as a whole. Commissioning through the local authority will also facilitate the integration of sexual health services, encourage linkages between services addressing related public health issues such as alcohol and drug misuse, reduce duplication of effort, and ensure that patients receive a seamless model of care. Such combined approaches are more effective and offer better value for money from public health budgets so should be encouraged.

4. However, whilst BASHH welcomes the commitment to public health through the ring fenced public health budget, we are concerned that the funds may not be sufficient to support the range of services needed in order to, improve health outcomes, reduce health inequalities, and avoid the higher costs of managing ill-health. Furthermore, with local authorities facing increasing budgetary pressure, BASHH is concerned that public health funds may be diverted to support non public health activities: historical experience (IAGSH 2006 report) shows that under financial pressure, sexual health services are often the first to get cut and funds are often diverted away from front line services. BASHH recommends that robust measures, such as regular audits, are put in place to ensure that the ring fenced funds remain truly rung fenced, and reach those frontline services the funding is allocated for.

5. In recent years, commissioners and providers of sexual health services have worked together to improve access to services, increase patient choice, improve the availability of testing and treatment for STIs, and put patients at the centre of their care. As a result, sexual health care is now provided by a variety of different sexual health providers, in a variety of settings, from HE colleges, and pharmacies, to GUM clinics providing fully comprehensive testing and treatment and more specialist case management. This approach has allowed areas to tailor their service provision to suit differing local needs.

6. However, BASHH is concerned that this increase in providers, alongside increased competition, may lead to a “race to the bottom” competition on price rather than quality. With commissioners facing ever increasing budgetary pressure, BASHH is concerned that “cheaper” services, which are less comprehensive, will be commissioned in place of fully comprehensive services: for example, clearly, a service which provides training and complex case management is more expensive than one which is limited to providing high volume, low cost STI screening.

7. In light of such concerns, BASHH advocates the principle of the “any qualified provider” rather than the “any willing provider” tender basis for public health service commissioning, in so far as this approach ensures that commissioners commission only those sexual health services that;

(a)Are underpinned by a national tariff system of pricing which is a true reflection of the services provided by sexual health services, and which will ensure a fair and level playing field.

(b)Provide rapid, open access to sexual health services.

(c)Are underpinned by BASHH standards for the management of STIs, which is endorsed by the Department of Health

(d)Are delivered by staff educated and trained to nationally recognised standards.

(e)Are commissioned as part of a consultant led community network.

(f)Are required to provide local data relating to prevalence of STIs and HIV and notify all disease outbreaks.

(g)Include in every locality comprehensive (i.e. including level 3), sexual health services which offer testing and treatment of STIs, opportunistic Chlamydia screening, and high quality partner notification, to all people regardless of residence.

8. Through proper enforcement, this approach should ensure the delivery of high quality, clinically effective, safe, and cost efficient services.

9. Looking at proposals for sexual health commissioning, BASHH is concerned that local authorities may not have relevant or sufficient experience of commissioning specialist clinical services such as GUM. Successful commissioning for public health services depends on a number of different factors relating to;

(a)The availability and use of public health data and the skills to interpret this.

(b)The availability of best practice public health guidance which sets standards and expectations, and

(c)The development of appropriate clinical partnerships to both share and draw upon expertise.

10. In the past NHS commissioning of sexual health services has been of variable quality. Experience has indicated that commissioners must be equipped with relevant knowledge and skills relating to sexual health, and that clinicians must be engaged in the commissioning process to help ensure both improved patient related outcomes and to help deliver service efficiencies. Mechanisms should be put in place to ensure that clinicians are able to feed in to the commissioning process for public health.

11. Commissioning service specifications should also insist that national clinical and quality standards, such as those produced by medical Royal Colleges, medical specialties, and NICE, are adhered to. Such guidance is vital to ensure both consistency and quality across all services provided for public health, and levers of accountability should be put in place to ensure this guidance is followed. BASHH has produced national guidelines for sexual health, which have recently been accredited by NHS Evidence, and therefore, as the representative body for sexual health, these guidelines should be used to provide the framework for commissioning of high quality sexual health services.

Arrangements for Funding Public Health Services (including the Health Premium)

12. As outlined above, BASHH is concerned that increased competition in the NHS will lead to a decline in the quality of sexual health care provided. This is exacerbated by the fact that the national tariff system for the NHS will not apply to the new public health service, under which sexual health service fall.

13. The London Sexual Health Programme has put a huge amount of work into developing an integrated sexual health tariff, which will allow for the development of prices that are setting-independent and could be used by a variety of providers. The work of the London Sexual Health tariff project is vital to ensuring that in the future SH 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, including for HIV.

14. The tariff prices which have been developed:

(a)Are in the best interest of patients and public health ensuring open access is maintained.

(b)Promote the integration of services (SRH/GUM).

(c)Provide value for money and are affordable.

(d)Do not destabilise services/providers or PCTs.

(e)Provide tariffs for SRH & integrated services that are robust.

15. International evidence suggests that without a fixed tariff system in place, the resulting situation will be a “race to the bottom” to provide the lowest cost services at the most competitive prices. Whilst this may be desirable for commissioners facing ever diminishing budgets, “cheaper” less comprehensive services can often be achieved at the expense of quality. BASHH, is concerned that any compromise on quality could lead to rapidly worsening rates of sexual ill health, increased spread of disease and ultimately, poorer health outcomes.

The Structure and Purpose of the Public Health Outcomes Framework

16. BASHH advocates outcomes in so far as they promote improvements in health and reduction in inequalities. For sexual health, which is linked to a number of different public health issues, outcomes should encourage collaboration of effort across the public health service, to improve quality and efficiency, reduce duplication of effort and ultimately help improve the health of the local population.

17. Whilst outcomes will be important for delivering health improvements, BASHH is concerned about the wholesale removal of all process targets. Unlike many other areas of public health, STIs and HIV are transmittable, but also avoidable. Therefore, for sexual health, as treatment forms a vital component of the prevention function, prompt access to sexual health services can bring about significant public health benefits:

(a)Early diagnosis of STIs reduce risk of costly complications and of onward transmission

(b)Earlier diagnosis and treatment of STIs, can prevent the development of long term and life threatening complications, including cancers and infertility

(c)Undiagnosed HIV increases the risk of passing on HIV: The NHS cost of providing lifetime treatment for people with HIV is increasing by £1 billion each year, whilst each time a person is prevented from acquiring HIV the NHS saves over £350,000.

18. Clearly, the realisation of better outcomes in sexual health is dependent on timely access to sexual health services. The 48 hour access target, which has underpinned sexual health services in recent years, is not a politically driven target, but one based on sound clinical rationale, with the result of improving clinical outcomes and delivering:

(a)Earlier access to STI testing, diagnostics, and treatment;

(b)A break in the onward chain of transmission; and

(c)Rapid public health benefits to the NHS, the individual, and the population.

19. Ten years ago, as rates of STIs increased, sexual health services were struggling to cope with demand, with median waiting times of around 10–12 days. The 48 hour access target was introduced to ensure people received prompt access to diagnosis and treatment. It is vital that all sexual health services, which are open access by nature, are commissioned as rapid open access services. BASHH is concerned about the impact that the removal of the rapid access requirement may have on the quality of services provided and the health of the nation.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

20. Sexual health is inextricably linked with a number of areas of public health, and with such a variety of providers operating within localities, Local Health and Wellbeing Boards (LHWBs) will need to play a central role in ensuring that communication and collaboration is facilitated between different service providers to;

(a)Help build effective partnerships.

(b)Ensure that efforts are not duplicated.

(c)Help the further integration of services.

(d)Ensure that local prevention initiatives are mutually reinforcing and/or complementary to each other.

(e)Ensure clinical and quality standards are being met across all providers so that the care delivered is both clinically effective and consistent.

21. BASHH recently launched “Standards for the management of STIs” which are endorsed by the Department of Health, and which represent current best practice in sexual health service provision. The standards were drawn up to facilitate the commissioning of services within a clinical network framework, and to enable healthcare professionals in different settings to work together to deliver quality care across providers.

22. Joint Strategic Needs Assessments will be crucial for the development of proposed Local Joint Health and Wellbeing Strategies. It is vital that sexual health services are included as a key component in this strategy, and that sexual health clinicians, as local leaders in their field, are involved in the development of these documents.

The Abolition of the Health Protection Agency

23. The HPA is the current provider of epidemiological information on sexual health in the UK. Its data collection and analysis methodology has been refined over many years and there are systems in place to ensure that the data is robust, avoids duplication and that there is widespread dissemination of analysis both on their website and in peer reviewed journals.

24. According to the proposals, Public Health England (PHE) will encompass all the current functions of the HPA. Whilst BASHH welcomes the commitment to health protection and hopes this may encourage further research and data analysis in the field of sexual health, BSHH is concerned that the proposals may have a negative impact on the provision of robust monitoring and surveillance data.

25. There is already a great deal of useful data that is supplied to the HPA which is not currently analysed as other key data is prioritised, and there is a concern that any reduction in personnel or resources may lead to a reduction in key epidemiological analysis and a reduction in the ability to respond quickly to requests for data analysis in outbreak situations.

26. Furthermore, there are some additional concerns about the potential loss of independence, credibility and trust that could arise out of the proposed move. Independence of the functions of the HPA is critical in terms of retaining credibility and the trust and confidence of the public, health professionals and others working in the field of health protection—locally, nationally and internationally: steps must be taken to preserve its independence.

The Future of the Public Health Workforce (including the Regulation of Public Health Professionals)

27. The UK has one of the worst rates of STIs in Western Europe, and therefore, excellent leadership in sexual health is vital to ensure that we meet the challenges that face the health services both now and in the future. Medical Royal Colleges Professional Medical Associations are the custodians of the postgraduate specialty medical curricula, and through leadership, develop training programmes that are underpinned by national clinical and quality standards, and which are set within overarching governance frameworks.

28. Effective training and ongoing education is essential to achieving high quality and safe care, which ultimately delivers cost savings for the NHS. BASHH is concerned that, unless incentivised, non NHS providers will not provide appropriate development opportunities and training in sexual health. A proliferation of non training services would have an adverse effect on education, training and research opportunities and ultimately, could lead to a reduction in the quality of patient care delivered.

29. BASHH Standards for the management of STIs set out a number of recommendations relating to training which are relevant for all providers of STI care. Recommendations include:

(a)People at risk of STI should have their care managed by an appropriately skilled health professional. Individual practitioners are responsible for maintaining their own competence but should be supported in this by their employing organisation.

(b)Agreed mechanisms should be in place for the assessment of clinical competence. These should be standardised and common across all professional groups.

(c)Services should be able to provide assurance that all professionals delivering care for the management of STIs can demonstrate that they are competent and remain competent to do so.

30. In line with the concerns about the proposed structures, BASHH further recommends that:

(a)Non NHS providers are subject to the same requirements with regards to the provision of education, training and continuing professional development as those working in the NHS.

(b)Such training and education meets nationally recognised standards.

(c)All services providing training are appropriately reimbursed.

(d)Royal Medical Colleges and professional bodies are actively involved in advising and approving education and training provided by all service providers.

About BASHH

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 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 (hereinafter referred to as “the Specialty”), 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.

There are currently over 700 members of the BASHH, over 70 of whom are overseas members. The Association membership includes medical practitioners, scientists in the field of medicine and other healthcare workers who have shown a commitment to the specialty, who have been duly elected Fellows, Members and Honorary Fellows. Criteria for commitment to the specialty are that the applicant should be currently working in or have contributed to the specialty or an allied field. Honorary Life Fellowship may be conferred on persons, including those not medically qualified, who have given distinguished service to the Society.

June 2011

Prepared 28th November 2011