1Funding and commissioning
Introduction
16.Adequate levels of funding, effective commissioning and provision mechanisms are key to facilitating the delivery of services and other activities that enable people to have good sexual health outcomes. The evidence we have received indicates that both the level of funding and commissioning arrangements fall short of what is needed: funding is insufficient, and commissioning is fragmented. Notably, the extent of this insufficiency and fragmentation is variable across the country: some local authorities have invested in sexual health and some areas have worked collaboratively to overcome commissioning challenges, but in neither case is that the norm.
Funding cuts
17.Cuts to spending on sexual health have been severe. Sexual health is predominately funded through local authority public health budgets, and in recent years this spending has fallen significantly: there has been a 14% real terms reduction in local authority spending on sexual health between 2013/14 and 2017/18 (figure 1).24 On our visit to Plymouth, we heard a sense of injustice that, unlike the NHS budget, local government public health spending was an “easy target for cuts”.25
Figure 1: local authority spending on sexual health has decreased
Source: The King’s Fund
18.As the graph above shows, advice, prevention and health promotion have been particularly hard hit, with a 35% reduction in funding.
19.There has been significant variation in funding decisions taken by local authorities across the country. Whilst some have prioritised sexual health, and protected or increased spending, others have cut spending by considerably more than average (figure 2). Troublingly, this variation often does not reflect local need,26 and there is a lack of national accountability for these local spending decisions.27
Figure 2: changes in spending on sexual health varies between local authorities
Source: The King’s Fund
20.Compounding difficulties, budget decreases have happened in tandem with increasing demand: attendances at sexual health services in England have increased by 13% from 2.9 million in 2013 to 3.3 million in 2017 (figure 3).28
Figure 3: attendances at sexual health services have increased
Source: The Local Government Association
21.Councillor Ian Hudspeth, Chairman of the Community Wellbeing Board of the Local Government Association, stressed the challenge posed to local government:
Ultimately it comes down to the funding we have, and the increase in appointments as well, from 2.9 million to 3.3 million. With that upward curve and the reduction in funding, we are rising to the challenge, but it is difficult, and we would appreciate the cuts being reversed.29
22.Providers and commissioners have also emphasised the challenge of reduced funding. The clear message we received was that persistent funding cuts have already had a negative impact on services. We heard that services are at risk of being cut back to the extent that they are unable to deliver fit-for-purpose, quality provision.30 At our roundtable in Plymouth we heard that funding cuts are particularly affecting the ability of providers and commissioners to focus on anything beyond the minimum that is required of them - mandated STI testing and treatment services and contraception services. The funding for prevention activities and wider supportive services has reduced considerably, meaning that outreach services for vulnerable groups have been stripped back.31
23.The service users we heard from have told us that funding cuts are affecting both the quality of and their ability to access sexual health services (case examples 1).
Case examples 1: service user views on funding
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Sexual health is so crucially important and funding is just being cut and cut. I would be on the phone trying to reach sexual health clinics that I didn’t know had actually been closed down. (homosexual woman aged 25–35) More funding is desperately needed. I am a student nurse and have been on the professional side from having a sexual health placement and also the patient side. Budget cuts mean Staff shortages and in turn means there are limited appointments available. (heterosexual woman aged 25–35) It makes no sense to cut funding and expect infections to stay the same. If people don’t get treatment in time infections will increase. More funding and more staff are needed. (homosexual man aged 46–60) |
Source: Summary of survey responses received
24.The Minister for Public Health and Primary Care acknowledged that cuts had had an impact on services:
[In 2010] we had to make really difficult decisions and we had to pass on savings to local authorities, who then passed that on to their services. You cannot make those kinds of savings without it having an impact.32
25.We heard about the short-termism of these cuts: that current funding cuts and the consequential effect on services represent a “false economy”33 and “will only compound acute pressures for the NHS and other services”.34 For example, at our focus group in Plymouth we heard that reduced HIV prevention activities, funded by local authorities, will lead to more cases of HIV and increase pressure on HIV treatment, funded by the NHS.35 The NHS Long Term Plan recognises that funding for services such as sexual health interplay pivotally with the NHS, directly affecting demand for NHS services.36
26.We reiterate the findings of our predecessors’ report Public health post-2013, that cuts to public health are a false economy. Cuts have a detrimental impact on the delivery of public health services. This affects service users, and risks widening health inequalities. They also increase demand for NHS services and jeopardise their sustainability, as preventable ill health is not adequately managed.37
27.We were concerned to hear “real and justifiable concerns that additional cuts will be applied to a sector now at breaking point”.38 Speaking to these concerns, the Minister told us he would make “a very robust case for public health spending in the forthcoming spending review conversations.”39
Fragmentation of commissioning
28.Our evidence was clear that the challenge is not solely in the amount of funding: mechanisms for its distribution and use are complex and fragmented. Professor John Newton, Director of Health Improvement of Public Health England, and Professor Jim McManus, Vice President of the Association of Directors of Public Health, stressed that funding and fragmentation are of “equal importance,”40 and that there is a particular need to address fragmentation given that it is the more readily remediable of the two:
There will never be as much money as we would like, I am sure, for these sorts of service, so it is essential to address the fragmentation.41
29.Since the implementation of the 2012 Health and Social Care Act, responsibilities for commissioning different elements of sexual health services have been split between local authorities, NHS England and clinical commissioning groups (CCGs) (figure 4).42 Breaking up interlinked services into different silos led to a greater number of system boundaries, relationships and funding pots to negotiate. Public Health England’s own review in 2017 recognised these failings and acknowledged that a more co-ordinated and collaborative commissioning model was needed.43 Although efforts have been made to address these problems, our evidence was clear that fragmentation remains a significant obstacle to effective commissioning.
Figure 4: commissioning responsibilities
Source: Public Health England
30.Collaborative, whole-system working between commissioners is essential to ensure robust care pathways for service users.44 The difficulties caused by the current fragmented commissioning arrangements are well known to those working in this area and the national bodies that seek to support them. In 2017 Public Health England and the ADPH published a review of commissioning highlighting the difficulties posed and making recommendations to support commissioners in tackling them. Their recommendations included piloting more collaborative approaches to commissioning; developing further guidance to support commissioners; supporting commissioners through networks and workshops; and improvements to data.45
31.PHE and the ADPH told us that ‘some progress’ had been made in implementing these recommendations.46 The evaluation of the two collaborative commissioning pilots is due to be published shortly. However, it is clear that there is still wide geographical variation in the extent to which local areas are able to commission and provide sexual health services effectively.
32.We heard that some areas have overcome systemic fragmentation to work collaboratively and deliver an approach that follows patient need. On our visit to Plymouth we saw an example of integrated working. We were told they “made it work” in the face of structural difficulties through close cooperation between providers, local authorities, the CCG and the NHS. Services were co-commissioned from pooled budgets. This level of collaboration had enabled services to be designed and planned in a way that spotted opportunities for services to connect.47 In our focus group we heard that another area had similarly developed an integrated approach, operating a lead provider consortium model.48
33.Our evidence has also been clear that, conversely, there are many areas where commissioning is not working well. In such instances, often, cooperation between commissioners is lacking. Professor McManus told us that “some of [his] members cannot get some parties to the table for love nor money.”49
34.Difficulties with cross-charging were given as an example of commissioning challenges. Local authorities have a legal duty to provide STI testing and treatment, and contraception services, to someone whether or not they are a resident of the local authority. Patient flows are significant: in 2016 34% of first attendances and 29% of follow up attendances at sexual health services were by out-of-area residents.50 Traditionally STI testing and treatment services have been charged by the provider back to the areas where the user is a resident (cross-charging), but contraception services have been absorbed by the host commissioner. The Department’s updated 2018 guidance on cross-charging states that it is a matter for local agreement whether cross-charging or host-funding is used for contraception, and “increasingly, areas are finding solutions that work for them.”51 At our focus group, however, we heard that areas are not finding solutions that work for them, and that guidance is “completely inadequate”. Some local authorities refuse to be cross-charged for contraception. One area anticipates a cost pressure of £230,000 to £250,000 if it is unable to successfully cross-charge for contraception. We also heard that this year some local authorities are even refusing to be cross-charged for STI testing and treatment. Cross-charging can also be taken as a demonstration of inconsistency and variability of approaches, as at our focus group we also heard that this was less of an issue in London as 31 boroughs worked together collaboratively on this issue.52
35.Commissioning complexities mean services are falling through the gaps. This problem is exemplified by the potentially damaging commissioning arrangements around cervical screening. Cervical screening is the commissioning responsibility of the NHS. At our roundtable in Plymouth we heard that it is difficult to fund sexual health clinics to provide cervical screening because “the funding pots were split so resolutely” following the 2012 Act.53 Troublingly, cervical screening in sexual health clinics has more than halved between 2013 and 2016, with many services restricting or removing their offer. Attendance for cervical screening is at a 20-year low, and it is clear that complex commissioning arrangements have contributed to this public health problem, particularly limiting opportunities for cervical screening in sexual health clinics.54 It is unacceptable for women to have to undergo entirely unnecessary separate intimate examinations for smear tests that could have been carried out at the same time as an STI screen or contraceptive fitting at a single visit.
36.Long-acting reversible contraception (LARC)—injections, implants and intrauterine devices and systems—is another example of a service for which commissioning arrangements are leading to unacceptable outcomes. LARC is one of the most effective forms of contraception,55 but use is relatively low at around 14% of women. This has been in part attributed to reduced provision in primary care due to commissioning issues. LARC is the commissioning responsibility of local authorities. Whilst local authorities pay for the contraceptive device itself, GPs feel that payment does not cover the full costs of providing the service as they are not always reimbursed for their time.56
37.Councillor Hudspeth told us that the key to where commissioning is and is not working is collaborative relationships between commissioners:
It is about the relationship between local authorities, CCGs and the acute hospitals. If you all have the ability to work together to provide the right outcome, and focus on that, rather than people saying, “This is our domain and our silo,” that is where the benefits are. Everybody has to think about the funding they have, which will always be limiting, and make best use of it, by saying, “Actually, if it’s over there, it’s slightly better than if it is in this box.”57
38.Professor Newton believed that concerning commissioner behaviour could be addressed within current structures but this requires concerted effort:
Where there is good collaboration, the problems can be solved, but collaboration is not easy, and it requires work and leadership.58
Tendering and procurement
39.We heard mixed evidence around the tendering and procurement process. The process requires staff to divert significant amounts of time away from clinical care to deliver tender submissions, in an environment where many clinics are already under-resourced.59 Dr Williams told us that it usually takes one consultant out of the service for two or three months.60 This challenge is compounded by the frequency with which providers are required to carry out this exercise, due to short contracts—every three years in Plymouth.61 On our visit to Plymouth we heard that “the same things across the country are being replicated over and over again,” which seems to be an unnecessary, time-consuming burden, with administrators having to be employed on both sides, solely to manage the contracting process.
40.There are also concerns about the outcomes of this process. We heard that whilst it is entirely reasonable to encourage services to be delivered in a cost-effective manner, competitive tendering has had a destabilising effect as competition has stifled the ability for providers to develop collaborative networks and relationships.62 We also heard that short-term contracts inhibit long-term service planning.
41.Conversely, we heard that tendering and procurement, if done well, drives up quality.63 We also heard that, under current arrangements, longer-term contracts are possible. Professor McManus told us that the contract in his area is eight years, and there are a number of other places with contracts of a similar length. We were told that more sustainable funding would allow for longer contracts of this type.64 Attendees at our focus groups in Plymouth were strongly in favour of longer contracts, up to eight or ten years, but many were still having to work within much shorter contracting arrangements.
42.What is clear is the unacceptable variation in experience of commissioning and tendering across the country. There is a need to build up good practice,65 and more should be done to support commissioners nationally. There remain too many examples of service users being disadvantaged because of a failure of collaborative working across systems in their best interests. Some areas have shown that this joint working is possible but it should not have to be the time consuming and uphill struggle. National and local leaders should be assisting in identifying and clearing the barriers to good practice.
Structural changes
43.The NHS Long Term Plan stated that “the NHS will consider whether there is a stronger role for the NHS in commissioning sexual health services” due to close links between these services and NHS care.66
44.We heard some calls to move responsibility for sexual health back to the NHS. These calls were largely based on the perception that sexual health services would be better funded under the NHS, as public health is an easy target for cuts.67 Dr Williams also gave reasons why clinicians would want to move back to the NHS: “most doctors would say that they wanted to be back in the NHS” as “that is where they historically are comfortable”.68
45.We are not convinced by these arguments. We reiterate the findings of our predecessors’ report, Public health post-2013, which welcomed the move of public health to local authorities in 2013. The report noted that local authorities are well placed to deliver public health objectives across their communities and in doing so can harness a far wider network of individuals who can help to improve public health. Our predecessors recognised the confusion and fragmentation of the public health system following the 2012 Act, but concluded that further large-scale restructuring is inadvisable.69 Another structural change could lead to further instability, which would be counter-productive to service delivery.70 Professor McManus highlighted that it took eighteen months for the system to settle down after the previous reorganisation.71
46.We have also heard broad agreement that the root of the problem is not where commissioning responsibilities sit, but the adequacy of funding. On that basis, moving sexual health back into the NHS would not address the key issue at hand. As Dr Williams argued:
we want adequately funded services, regardless of where they sit. Rearranging the deckchairs is not the issue; it is about fundamentally putting in the right package of money.72
47.However, as our previous reports have shown, a system where services are commissioned locally inevitably leads to local variation. Some degree of local variation is appropriate, reflecting the different needs of different populations. However, the variation evident in the commissioning and provision of sexual health services—where people in one local area have access to the latest preventative treatment for HIV and those in the adjacent area do not; and where commissioners in some areas are able to work collaboratively to provide cervical screening within sexual health services, but others are not—clearly shows that acceptable standards are not being met in all areas, and that further support and direction for commissioners is needed.
48.We heard from the Association of Directors of Public Health that a single, agreed, national set of quality standards would be a useful tool to standardise practice and improve quality;
There is currently no single joined-up view of what good looks like… there is no single national set of quality standards, or minimum service specifications.73
49.Agreed standards—spanning all types of sexual health provision—would also provide a clear basis for benchmarking and monitoring local areas’ performance. In our reports on suicide prevention, we recommended a strong and clear quality assurance process to strengthen scrutiny of local authorities’ performance on suicide prevention. This recommendation is now being implemented via a national quality assurance process of monitored self-assessment. This has resulted in a high level of local authority engagement with this issue, and an independent evaluation of the learning from this process is to be published shortly.74
Conclusions and recommendations
50.Cuts to spending on sexual health have been severe. Local authority spending on sexual health services has decreased by 14% between 2013/14 and 2017/18. This has happened in tandem with mounting demand. Attendances at sexual health clinics have increased by 13% over the same period. Inevitably, resources are stretched, and the sector has been described as “at breaking point.” This has inescapably affected the delivery of services and, ultimately, outcomes for service users.
51.There is a need to also address the unacceptable variation in joint collaborative working across commissioning. The reasons for this need to be addressed including by making sure all areas are supported to follow the best practice.
52.Sexual health must be sufficiently funded to deliver high quality sexual health services. Cuts to spending on sexual health, as with other areas of public health expenditure, are a false economy. Looking forward to the Spending Review, the Government must ensure sexual health funding is increased to levels which do not jeopardise people’s sexual health. Inadequate prevention and early intervention increase overall costs to the NHS.
53.As part of work to develop a new national sexual health strategy, we recommend that the national sexual health working group should set out the minimum levels of spending that will be required to ensure that all local areas are able to deliver high quality services.
54.Commissioning mechanisms fall short. Fragmented, seemingly unnavigable commissioning responsibilities have had a damaging impact on the delivery of sexual health services. This has had a harmful impact on outcomes for service users, a prime example of which is the nonsensical situation with cervical screening.
55.Nonetheless, we do not support calls for responsibility for sexual health services to be returned to the NHS. Efforts would be better directed at making the existing framework work, and supporting joined-up commissioning. Rather than either the NHS or local authorities taking sole responsibility, work should be done towards developing a joined-up system where nothing gets through the cracks. We have heard this conclusion before, and past actions have been insufficient to achieve the required change.75
56.A wholesale reorganisation of commissioning responsibilities—moving responsibility for sexual health back to the NHS—is not the answer to the problems with commissioning which our witnesses have identified. As our predecessors concluded in their report on Public health post-2013, there is a need to address system boundary issues in the best interests of patients. Strengthened collaboration is key, and longer contracts should be introduced to enable better strategic planning and to lessen the burden that tendering currently imposes.
57.The difficulties in delivering effective, joined up sexual health commissioning are well known, and Public Health England and the Association of Directors of Public Health have taken steps to address them through the actions set out in their 2017 review. But despite these efforts, there is still marked variation in how well local areas are able to commission sexual health services, and to work collaboratively. The national sexual health strategy, supported by a senior working group, must bring new impetus to work to drive forward change and improve services for patients.
58.Recognising the complexity of the provider and commissioner landscape in sexual health, the national sexual health working group should consist of senior representation from all relevant groups, including PHE, NHS England, local government, patient representatives, CCGs, and different provider groups.
59.Building on the recommendations set out by the ADPH and PHE 2017 review, the strategy should aim both to identify and to disseminate best practice, and to work supportively but robustly with areas which need to improve.
60.The strategy should set out one clear set of national quality standards for commissioners to adhere to, encompassing all aspects of sexual health. The standards should provide a holistic and unified overview of what good looks like, including setting out how all services should work together, and setting out standards for effective commissioner behaviour. Further recommendations for what these quality standards should include are set out in subsequent chapters.
61.The national sexual health strategy should also set out a clear framework through which local areas will be assessed against the quality standards, with the findings made public both to ensure best practice is widely shared, and to increase public accountability.
24 The King’s Fund, Sexual health services and the importance of prevention
25 Annex 1
31 Annex 1
35 Annex 1
36 NHS, Long Term Plan
37 Health and Social Care Committee, Public health post-2013
42 Public Health England, Commissioning local HIV sexual and reproductive health services
43 Public Health England, Sexual Health, Reproductive Health and HIV: A Review of Commissioning
45 Public Health England, Sexual Health, Reproductive Health and HIV: A Review of Commissioning
50 Department of Health and Social Care, Sexual Health Services: Key Principles for Cross Charging
51 Department of Health and Social Care, Sexual Health Services: Key Principles for Cross Charging
52 Annex 2
53 Annex 2
56 Faculty of Sexual and Reproductive Healthcare (FSRH) (SLH0027); Royal College of General Practitioners (SLH0075)
61 Annex 2
62 Annex 2
66 NHS, Long Term Plan
69 Health and Social Care Committee, Public health post-2013
74 Suicide prevention follow up inquiry, Health and Social Care Committee, January 2019
75 Health and Social Care Committee, Public health post-2013
Published: 2 June 2019