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Jan Clarke

Dr Jan Clarke is a Consultant Physician in Genitourinary Medicine at the Leeds Teaching Hospitals Trust and current President of the British Association for Sexual Health and HIV (BASHH). In this month’s eFeature she offers a sharp view from the clinic, examining the impact the new health and social care commissioning environment has had on sexual health and HIV clinical services.  She highlights ‘the good, the bad and the sometimes ugly’ consequences to date; and maintains that to ensure the future ‘good health’ of these services, robust model contracting templates need to be used that recognise the requirement to deliver both basic and complex sexual health care, encompass the needs of specific vulnerable groups and retain seamless care across the patient pathway.

A healthy community needs healthy sexual health services

Most adults have sex – and most will enjoy healthy sex without disease, coercion or exploitation. When someone decides they want a checkup, gets a worrying symptom or a phone call from a partner with a problem they might have shared then they need a sexual health service. They need rapid access to expert advice, deserve confidential and respectful services and don’t want to have to disclose their personal details repeatedly to get a referral. Since well before the NHS, we have had a network of free walk-in services across the UK to meet their needs and treat their sexually transmitted infections (STI). 

Are the services still in good health following the recent upheavals in commissioning?

Sexual health is not only swabs and pills...

...but also prompt access, onsite diagnosis, immediate treatment and tracing of sexual partners to minimise community impacts of STIs - a clinical public health service the envy of many countries. Genitourinary medicine (GUM) clinics also provide the core outpatient services for testing and treatment of HIV.  Co-location of HIV testing and outpatient treatment gives the UK world class rates for retention of HIV positive patients into care and treatment, and for successful viral suppression. 

In recent years, many services have integrated with community contraceptive clinics and sexual and reproductive health (SRH) colleagues to develop sexual health clinics. Complex contraception and reproductive health needs of women are brought together with GUM and HIV care for all ages and genders. Risk assessments, brief interventions on behaviour modification, relationship advice, managing complex STIs and targeting vulnerable groups at particular risk of infection with STI and HIV, especially younger people, black and minority ethnic communities and men who have sex with men (MSM) are part of the spectrum of services. 

We work with colleagues in the detection and management of child sexual exploitation. We train not only our own future specialist doctors and nurses but also local non-specialists. GUM clinics have embraced service modernisation, incorporating information technology and social media tools to expand our screening and outreach while retaining safe care pathways for those needing face to face care. Our active research and innovation agenda is illustrated by the PROUD study - showing daily HIV drugs (PrEP) for those at risk of HIV prevent infection - a world class piece of work based on real life work in 13 English GUM clinics.  

But Sexual Health Services don’t appear on the agenda...?

...they rarely do! Since, for confidentiality, many clinics have stood a little apart from acute and community services, the true size and scope of the services may surprise you. Overall, 1 in 5 adults will visit a sexual health clinic at least once in five years. Over 1 million HIV tests were performed in GUM services in 2013, and a total of almost 450,000 new STI diagnoses were recorded. And about a quarter of all 16-25 year olds have been screened for chlamydia, with about a third of those tests done in our clinics.

What impact has the new health and social care commissioning environment had?

In April 2013 English local authorities (LAs) became responsible for commissioning services for sexual health, HIV prevention and testing. Treatment and care for HIV remained as a specialised service commissioned by NHS England, while abortion services are commissioned by clinical commissioning groups (CCGs). After a standstill period, many areas have commenced or completed competitive tendering for the GUM and contraception services; some have decided not to tender and retained their current providers. Others have used section 75 of the NHS Act 2006 to develop joint commissioning between LAs and the NHS, with the aim of retaining an integrated approach between sexual health and HIV.  The remainder have announced intentions to procure within the next two years. 

The good bits...

Services overdue a makeover are now being revamped; examples such as developing outreach, offering longer opening hours and driving integration with SRH services are widespread. Funding has actually increased in a few areas. Critical appraisal of practice is always good - and describing your current and future visions of good prevention and care in sexual health to others challenges complacency. New collaborations in section 75 arrangements are building understanding across the health and social care community.

...the bad...

Competitive tendering in the local authority legal environment is very new to most NHS managers, and commissioning clinical services for sexual health is new for local authorities. Issues were almost bound to arise, even with model service specifications and other optional guidance. Unfamiliarity means everybody struggles to deliver on both structuring the specifications and on formatting bids. The necessary involvement in such work of senior clinicians detracts from current service delivery and costs a fortune. Where bids are successful, further mobilisation work on re-structuring services is compressed into very tight timescales. Where existing providers lose, expert nurses and doctors may transfer away rather than work in unfamiliar organisations. Keeping patients and communities informed about the changes, let alone attempting engagement of this very sensitive and reticent group of service users is a major challenge. 

The main negative impact to date is service stagnation because of the huge volumes of work in wrestling with the process of tendering

...and the ugly...

Dysfunctional commissioning processes in some areas undergoing competitive tendering have caused disruption to clinical services which are being repaired by mutual effort of providers and commissioners. Some of my colleagues face their fourth procurement round in two years.  A number of local authorities have stipulated sexual health facilities be sited in multiple venues without consideration to HIV outpatient care, risking the retention in care of those diagnosed with HIV in STI clinics and  leaving HIV patients without ready access to STI care. Some areas have over-simplified specifications, risking a lack of local expertise to deal with complex patients and rendering services unattractive to MSM and men in general. Postgraduate training is compromised where service specifications have failed to take funding and resource requirements into account. Undergraduate teaching, research and innovation are hardly ever considered.

What about the money?

Sexual health, even though it is a clinical service, does not feature in the NHS plan for sustained and protected funding. Ring fencing of the public health budget in LAs is expected to disappear in 2016/17. In practice, sexual health services are already being affected within that ring fence. Some areas report projected reductions in funding of 10-40% for the next financial year with cuts of up to 50% mooted over the next 5 years. Budgets for procurements may be set at levels up to 25% below current funding, with punitive tariffs for seeing more activity than in previous years. Cuts of that severity and bewildering speed mean expert staff are being lost, access will deteriorate and community control of infection will be put at risk.

So what’s the prescription?

Robust model contracting templates need to be used that recognise the requirement to deliver both basic and complex sexual health care, encompass needs of specific vulnerable groups, and retain seamless care from HIV testing into ongoing outpatient HIV care. Workforce development and specialist services of local relevance need to be contracted for alongside routine clinical care. We don’t know if whole system commissioning options will deliver better outcomes but fragmentation of HIV from GUM certainly has started to damage patient care quality.

We face a crisis in public health no local authority would wish to promote. A much higher proportion of adults in a local community are sexually active compared with those who smoke, are obese or have drug and alcohol problems. Cabinet members and local officers need to be made aware that sexual health is a key clinical component of public health and is not just a lifestyle choice. Sex is part of life, and a healthy community needs healthy sexual health services. 

The content of all eFeatures represents the views and opinions of the authors. MEDFASH does not necessarily share or endorse the views expressed within them.