Posted 2nd Apr 2014
It was on a cold January day more than two years ago when I first heard that two of the local providers of sexual health services for Leicester, Leicestershire and Rutland had given notice of their intent to withdraw their services from the health and local authority sector. Confirmation of this from Janet Hutchins, my colleague in Leicestershire County Public Health, started the biggest and most challenging learning curve of my career.
The Health and Social Care Act 2012 gave local authorities the responsibility for commissioning open access sexual health services, potentially providing an opportunity to make service improvements for patients. Janet and I had tried for years to get an integrated sexual health service and our work in the previous six months with Pathway Analytics [i] had provided evidence that implementing the integrated tariff route would be cost saving. With this in mind, and after much soul searching, Janet and I both recommended to our respective Directors of Public Health that we should develop an integrated model for sexual health across Leicester, Leicestershire and Rutland. Here’s how we did it.
Getting the mandate
Commissioning sexual health services was still the responsibility of the shadow Clinical Commissioning Groups (CCGs) up to 1st April 2013. A Programme Board was set up with representatives from the three CCGs [ii] and three local authorities. This Board agreed the procurement of a full integrated sexual health service, which would include the youth sexual health service and chlamydia screening. It was also agreed that it would not include HIV treatment and care.
We received some criticism about this but, as the latest PHE [iii] bulletin points out, NHS England commission a provider based service making joint commissioning difficult and potentially limiting any competition. Indeed, at the time of decision making there was no clarity about the use of section 75 for collaborative commissioning of sexual health and HIV services.
A Clinical Engagement group was set up with local lead clinicians in genitourinary medicine and contraceptive services, local GPs with an interest in sexual health and nurses involved in primary and secondary care. This group developed the model. The meetings were facilitated by external clinical and non-clinical facilitators provided by MEDFASH to ensure impartiality and credibility with local clinicians. Wider opportunity for input into the model was also provided via the local multi-agency sexual health network.
The needs of the areas were provided by sexually transmitted infection (STI) data, contraceptive data and information from service reviews including the views of young people. The public health departments were central to providing this data. The areas had very different needs. Leicester is a large urban area with a culturally diverse population, high under-18 conceptions and high HIV prevalence. Leicestershire and Rutland counties both have rates of under-18 conceptions and HIV prevalence that are below national averages.
A market engagement event was held to inform potential providers of the proposed procurement process (including timescales) and to consult on options being considered (such as the inclusion of managing sexual health Locally Enhanced Service (LES) contracts). This received positive feedback and is likely to have increased the bids received.
The model developed is an integrated sexual health service from level 1 to 3. This includes chlamydia screening, a young people’s service, a sexual health network and training
An external clinician was commissioned to look at clinical standards as part of the process to develop the model. There were initial difficulties identifying a clinician from out of the area to prevent conflicts of interest and with expertise in integrated sexual health.
The Programme Board was chaired by public health, which would be moving from NHS to the Local Authority during the procurement timespan. The three local authorities were briefed and agreed to commission jointly. The steering group had legal, finance and procurement leads. It was agreed that rather than one from each LA there would be one of each representing all LAs, with responsibility for feeding back to colleagues in the other LAs.
The CCGs agreed that this was a transitional commissioning issue. Greater East Midlands Commissioning Support Unit (CSU) was asked to lead on the procurement process, and a project manager was appointed.
The changes in the Health and Social Care Act 2012 have resulted in different parts of sexual health being commissioned by different parts of the public sector. In commissioning a new service that did not include HIV, terminations of pregnancy (TOPs) or vasectomies, it was important to ensure that clear patient pathways would continue. To aid this a small steering group was set up to ensure that these were addressed by new commissioners.
Ongoing education and training of medical and nursing students
The original services provided specialist registrar training in GUM and Community Sexual and Reproductive Health. For the future sustainability of these specialties it was considered important that the training arrangements continue with any new provider. This needed to be included in the specification and required work with the Local Education and Training Board (LETB) including a review of the quality standards within the provider bids.
A clarification event was held for the potential providers to present their bids to two panels – a main panel representing the full procurement team and a panel of young people. At the end of the interviews the young people presented their findings to the main panel. This was an excellent presentation and a process that we would recommend.
Selecting the provider was undertaken by the full team including representation from the LETB, CCG Quality department, human resources and the external clinician.
Once the new provider had been selected there was a Mobilisation Group set up and work streams to ensure the safe transition to the new provider.
The main issues that needed to be considered were:
Transfer of undertakings (protection of employment)(TUPE): this was a new model, new provider and there had been three previous providers. TUPE legislation means that the new provider is not entitled to have all the information about the transferring staff up until a period of between 14 to 90 days before the start of the new service. This makes planning and service changes difficult to implement from the beginning of the contract period.
Assets and Buildings: the new provider did a full clinical and safety audit of the buildings that were used and decided on a way forward. We had mandated one of the main hubs in a LIFT (Local Improvement Finance Trust) building. The identification of ownership was an issue.
IT and information: this continues to be an ongoing problem. A shared IT database with the HIV service was agreed. This ensured one patient record between the two services, and was subject to a data sharing agreement.
Pathways: Working across three CCGs meant going to three sets of meetings to get pathways agreed and hoping that they would all make the same decision. At the same time CCGs had new staff and were taking on the commissioning of services that they had not commissioned before e.g. abortion and vasectomy services.
The new integrated service started on 2 January 2014. There have been some initial teething problems as happen with many services.
But, what went well?
From the commissioners’ perspective:
From the provider’s perspective following the award of the contract:
What could have been improved from the provider’s perspective?
Would we do this again?
Yes. There are always challenges in change but also huge opportunities. The tender process is complicated and time consuming and it brings up a lot of emotions for staff who are being transferred under TUPE, as there is much fear of the unknown. However these negatives are outweighed by the positives of being able to make beneficial changes and provide a service which meets the needs of service users, professionals and the wider public.
The new service being provided in Leicester, Leicestershire and Rutland will continue to improve and we will work through any further challenges together to ensure the needs of service users remain at the core of any future developments.
[i] Pathway Analytics is a management consultancy that specialises in evidenced-based economic analysis for healthcare.
[ii] Leicester City CCG, West Leicestershire CCG and East Leicestershire & Rutland CCG
[iii] HIV, sexual and reproductive health: current issues bulletin 3: Commissioning HIV services, DH/PHE February 2014
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