The role of local authorities in health issues

Written submission by the British Association of Sexual Health and HIV (BASHH) and the Faculty of Sexual and Reproductive Healthcare (FSRH)

1.0 Executive Summary

1.1 BASHH and the FSRH are the two leading bodies representing the interests of those involved in sexual and reproductive healthcare (SRH) and HIV in the UK. The FSRH has a membership of nearly 16,000 doctors, approximately 80 per cent of whom work in General Practice and there are currently over 1000 members of BASHH, primarily specialists and other medical practitioners and nurses working in Genitourinary Medicine (GUM) services.

1.2 The transition of public health to local authorities is often highlighted as the stand-out positive aspect of the Health and Social Care Act, enabling more joined-up work on tackling the wider social determinants of ill-health and preventing avoidable morbidity and mortality.

1.3 The transition includes transferring responsibility for commissioning clinical sexual and reproductive healthcare services (SRH) and genitourinary medicine (GUM) services to local authorities. SRH services are also sometimes called contraceptive services or family planning, but in practice provide a wider range of care than just contraception.

1.4 BASHH and Faculty have serious concerns about how the new financial and structural arrangements for sexual health services will affect future access to services and impact on service standards and training.

1.5 The last ten years have seen unprecedented improvements in sexual health services with sexually transmitted infections (STIs) remaining consistent since 2006, after rising by 20% between 2001 and 2005. However, compared with many other western European countries, England has high rates of STIs and unintended pregnancies which present significant challenges for SRH.

1.6 Open and unrestricted access to high-quality services with well-trained staff is vital to ensure these challenges are met. Indeed there is a statutory requirement, dating back to the Venereal Diseases Act of 1917 on sexual health services to provide open access and both GUM and SRH (Contraception) services are designated open access services. This means that everyone, irrespective of age or location of residence or GP registration, should have access to a high quality services to for STI treatment and contraceptive provision in a timely manner, and without need for referral by a GP. Through secondary legislation, the new Act will places a mandate on local authorities to provide ‘appropriate access’ to open access sexual health services. The secondary legislation has yet to be brought to Parliament, however there remains significant uncertainty about what ‘appropriate access’ means. There are concerns that access may be restricted by age, place of residence, or services are unable to provide care in a timely manner making service ‘open access’ in name only.

1.7 Following an assessment of the clinical, organisational and financial risks of the Government’s proposals, BASHH has concerns about the potential for fragmentation of services, the capacity of local authorities to commission clinical sexual health services, and the proposed funding mechanisms for sexual health. If these concerns, many of which are shared by local authorities, are not addressed, there is a high chance that access to sexual health will be restricted, service standards and training will be compromised and the improvements seen in SH over recent years will not be sustained..

2.0 The introduction of a public health role for councils

2.1 BASHH and the FSRH welcome the increased local council role in public health. Local authorities have always had a role in public health; between 1948 and 1974 Local Government had responsibility for public health through local authority medical officers for health.

2.2 Local authority public health commissioning can excel where it can develop local solutions to the local variations in public health, and where it can enable joint approaches to be taken with other areas of local government's work (such as housing, the environment, transport, education, planning, children's services, social care, environmental health and leisure) and with key partners (such as the NHS, police, business, early years services, schools and voluntary organisations).

2.3 In terms of SRH, local authorities are well placed to undertake ‘upstream’ sexual health prevention, including outreach, interventions in schools and care for the homeless, and will be able to co-ordinate interaction between organisations at a local level especially regarding drug and alcohol misuse and sexual health.

2.4 However, as part of the public health reforms, local authorities will also be given commissioning responsibility for some components of sexual health services from the NHS, funded through the ring-fenced public health budget. As discussed below, we have serious concerns about the capacity of local authorities to commission complex clinical sexual health services.

3.0 The adequacy of preparations for the new arrangements

3.1 BASHH and the FSRH are concerned that local authorities have not considered the systems or expertise that will be necessary to commission clinical sexual health services.

3.2 In 2011, the Government concluded that commissioning responsibility for abortion, sterilisation and vasectomy were not appropriate for local authorities and should be moved into the NHS, citing their ‘highly clinical, and in most cases surgical, nature’ (Department of Health "Public Health in Local Government" factsheet) which require ‘a robust clinical, regulatory and legislative framework’. The Government concluded that abortion, vasectomy and sterilisation should remain within the NHS and be commissioned by clinical commissioning groups. The Government said in December 2011 in a public health fact sheet on commissioning responsibilities that "A consultation on this revised recommendation will begin in due course." We are not aware of any plans however, that this consultation will be published in advance of the transition.

3.3 Due to their highly clinical, and in many cases surgical, nature, clinical sexual health services require the same ‘robust clinical, regulatory and legislative framework’ required by abortion, vasectomy and sterilisation services. BASHH and the FSRH believe that taking on clinical commissioning in relation to sexual health should be evaluated through the same decision-making process that abortion, vasectomy and sterilisation were reviewed.

3.4 Examples of surgical and complex non-surgical services:

· Intrauterine procedures sometimes requiring ultrasound at the same time.

· Endometrial biopsy as part of contraceptive care.

· The location and removal of "lost" contraceptive implants which can be deep within the arm and require very specific imaging and surgical skills.

· Genital skin biopsies for the diagnosis of malignant, premalignant and other conditions.

3.5 Examples of non-surgical services, but complex medical services include:

· The treatment of syphilis and primary herpes in pregnant women with risks of neonatal morbidity and mortality.

· Treatment of tertiary syphilis, lymphogranuloma venereum, pelvic inflammatory disease, epididymo-orchitis and psychosexual care.

· The management of women with complex medical conditions that impact on safe contraceptive use.

· The management of women with complications of contraceptive use.

· Post-exposure prophylaxis following sexual exposure (PEPSE) is an essential service for sexual health services to provide as outlined in a letter from the Chief Medical Officer in 2006. It is an emergency treatment of anti-retroviral therapy (ART) for people who are HIV negative.

3.6 Much of this personal medical healthcare forms a continuum with current NHS clinical care delivered in primary and secondary care and is not primarily public healthcare.

3.7 We are concerned that local authorities do not have the clinical and information governance infrastructure, systems and leadership to safely commission clinical sexual health services. This includes having risk registers in place, ensuring there are appropriate audit systems and other procedures that mean the right questions are being asked of the commissioning decisions. These questions should be led at Board level, by people with the requisite experience and expertise of dealing with clinical risks.

3.8 Without the necessary clinical and information governance systems to commission clinical services staff may undertake procedures without the appropriate competencies, standards and guidance may not be followed properly, and patients will increasingly be put at risk.

3.9 Consequently Local Authorities will have to establish complex commissioning infrastructures, bear an unpredictable and significant cost on a ring-fenced public health budget, and will be distracted from their primary focus - delivering ‘upstream’ services.

3.10 Requiring each local authority to establish the requisite infrastructure and systems, not required by other public health functions (including alcohol and drug services which do not have the same clinical risks), seems unduly burdensome for a single commissioning function. Financial pressures on local authorities may also squeeze an already under-resourced scrutiny function.

3.11 There has been speculation that commissioning responsibility for clinical sexual health services could be sub-contracted, potentially to Commissioning Support Units. This would effectively mean that funding is being granted from a national Health department to local authorities to outsource commissioning to Health department Commissioning Support Units to commission NHS providers. This is clearly not an efficient way for funds to be moved around.

3.12 The future of medical training by local authorities also remains unclear. Currently most post basic clinical training in sexual and reproductive health for doctors and nurses, including those working in general practice, paediatrics and obstetrics and gynaecology, takes place in specialist Sexual Health services. This requires not only all specialist services to be commissioned to provide training, but also to have the expertise, case mix and funded time to deliver such training. It is unclear whether local authorities would want to take on responsibility for training health professionals, employed by the NHS to deliver NHS services.

4.0 The objectives of the new arrangements and how their impact can be measured

4.1 One of the principle reasons the transition of public health to local authorities was broadly welcomed, was because it separated public health from the ‘sickness’ service. Despite repeated attempts by Ministers over the years to prioritise public health, it has generally been recognised that when money is tight it is diverted from public health into other parts of the service.

4.2 Looking forward, the ring-fenced budget for public health is likely to stay flat at best, and probably decline for many local authorities as the funding allocation switches to a needs-based formula. There are also serious concerns that the ring-fenced budget is not in itself large enough to fulfil our new public health responsibilities. The Department of Health has even conceded that the spending estimates for Public Health "may have been an underestimation" in many areas.

4.3 It is currently estimated that sexual health will constitute 25% of the total £2.2bn local authority public health budget. Critically however, it is hard to accurately forecast the cost of clinical sexual health due to the open access nature of the services, meaning like A&E services, anyone can access any clinic around the country for prevention, testing and treatment.

4.4 Whilst the public health budget will remain flat the financial demands for sexual health services will continue to increase as the rates of STI infection continue to rise. As pressure builds on simply managing residents’ (and non-residents) sexual health, Local Authorities will fall into the same trap that has befallen public health in the past where budgets are channelled towards treatment to the detriment of focus on promotion and prevention in sexual health and other areas.

4.5 If Local Authorities focussed just on sexual health promotion and prevention, which is what they are very well placed to do, and did not have responsibility for commissioning complex clinical services then they would be better placed to achieve the principle objectives of their public health function.

5.0 The intended role of Health and Wellbeing Boards in coordinating the NHS, social care and public health at the local level

5.1 Joint working and communication is fundamental for the delivery of sexual health care that is comprehensive, avoids duplication, meets high standards, is clinically safe, and cost effective. Sexual and reproductive healthcare, which is provided across a range of settings (primary care, community clinics, schools etc) and by a variety of providers, is also inextricably linked with a number of areas of public health such as alcohol and social care.

5.2 However, BASHH and FSRH have concerns about the capacity of Health and Wellbeing Boards to ensure that sexual health issues are prioritised, given that they may meet as few as 4 times a year and will have a wide-ranging remit to cover.

5.3 BASHH and the FSRH also have some concerns about the potential for strongly held political views on Health and Wellbeing Boards impacting on the provision of local sexual health services. The decision to remove the responsibility for commissioning abortion services from local authorities has been welcomed due to concerns that pro-life views held by some councillors who may sit on Health and Wellbeing Boards will result in funding not being forthcoming for abortion services or indeed services being decommissioned. However, Councillors with strong political views may also have similar views on other the provision of services for gay men and sex workers, the use of expensive prophylaxis following potential sexual exposure (PEPSE) to HIV, and the provision of contraceptive services to young people, including those under 16.

5.4 The provision of advice and treatment to young people, in particular, often receives prominent media coverage, and is likely to be a source of heated political debate in a number of Local Authority Health and Wellbeing Boards. It is important to note that high quality sex and relationships education, combined with access to free, confidential sexual health services delays the age young people first have sex and increases the likelihood they will use contraception when they do have sex. High quality services and access to a full of contraceptive methods also reduces teenage pregnancy. Furthermore, young people’s right to confidentiality is enshrined in case law after Lord Justice Fraser ruled in 1986 that it is legal for health professionals to provide contraceptive advice and treatment if the young person has sufficient maturity and judgement to enable them fully to understand what is proposed.

6.0 All local authorities can promote better public health and ensure better health prevention with the link to sport and fitness, well-being, social care, housing and education;

6.1 Sexual and reproductive healthcare is provided across a range of settings (primary care, community, schools etc) and by a variety of providers. It is also inextricably linked with a number of areas of public health such as alcohol and social care. Joint working and communication is therefore fundamental for the delivery of sexual health promotion and prevention that is comprehensive and cost effective.

6.2 In terms of SRH, Local Authorities are well placed to undertake ‘upstream’ sexual health prevention, including outreach, interventions in schools and care for the homeless, as they are well placed to co-ordinate interaction between organisations at a local level especially regarding drug and alcohol misuse and sexual health.

7.0 Barriers to integration, including issues in multi-tier areas

7.1 The NHS reforms transfer responsibility for commissioning sexual health services across a number of new organisations, which will result in fragmentation between local authorities, clinical commissioning groups, the National Commissioning Board and Public Health England.

7.2The allocation of commissioning responsibilities are as follows:

· GP contraception: by the NCB

· GP provision of Long acting contraception

· Specialist Sexual & Reproductive Health Services (which includes contraception): by local authorities/public health

· Some surgical procedures of Sexual & Reproductive Health Services: by clinical commissioning groups

· Abortion services: by clinical commissioning groups or the NCB

· Genitourinary Medicine Services: by local authorities/public health

· Some surgical procedures of Genitourinary Medicine Services: by clinical commissioning groups

· Provision of PEPSE within Genitourinary Medicine Services: by local authorities/public health

· HIV treatment and care: by the NCB

· Sexual assault services: by the NCB

· Psychosexual services: unclear

7.3 The multiple fragmentation of commissioning could restrict ambition for more integrated services designed around the patient, allow cherry-picking and adversely impact on training.

7.4 In response to concerns raised by BASHH and the British Association of HIV around this issue, the Department of Health have undertaken a survey of procurement intentions regarding the tendering of sexual health services and implications for HIV treatment and care. The deadline for responses was 12 October and the Department are currently analysing the results and identifying any further actions that are needed.

7.5 As highlighted above, SRH services also have clinical pathways which will overlap with NHS funded services, particularly gynaecological care. A common example is that a woman may have a contraceptive device fitted for gynaecological reasons rather than for contraceptive purposes, yet it is uncertain who would be responsible for paying this provision. Without payment structures in place, there are real dangers that the fragmentation of the commissioning infrastructure will result in patient’s not receiving the care and treatment they need delivered by those most skilled to deliver that care.

7.6 BASHH and the FRSH recommend the establishment of sub-national, supra-local bodies which would facilitate joined-up commissioning between GUM and SRH and the different aspects of NHS services related to Sexual Health such as gynaecology and HIV services.

8.0 The financial arrangements underpinning local authorities’ responsibilities, including the ring-fencing of budgets and how the new regime can link with the operation of Community Budgets

8.1 Local authorities are under significant financial pressure, in particular from social care budgets. Furthermore, the Department of Health has conceded that spending estimates for Public Health "may have been an underestimation" in many areas, leading to concerns that the ring-fenced money allocated to local authorities may not be a true reflection of the amount needed.

8.2 Financial pressures may result in Local Authorities commissioning services according to block contracts, rather than a tariff based system where services bill according to the number of patients they see.

8.3 Sexual ill-health does not respect local authority boundaries; many men and women require sexual health services when they are away from their borough of residence. The open access nature of services means that SRH care is dependent on a system that allows cross charging.

8.4 Without a tariff such cross-charging arrangements may prove difficult. For instance, some commissioners have said that from 2013 they do not intend to pay a tariff for their sexual health attendees seen in other areas.

8.5 The lack of effective cross-charging will put increasing pressure on the London and provincial city clinics and will certainly not encourage clinics to provide excellent and renowned services. In fact it may perversely promote poor service provision to discourage people from the surrounding areas. In turn this will lead to increased prevalence of STIs, HIV and unintended pregnancies.

8.6 The continuation of the sexual health tariff would support the 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, and support patient choice."

For more information on the Faculty of Sexual and Reproductive Healthcare and the British Association of Sexual Health, please see their websites:

November 2012

Prepared 8th March 2013