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eFeature

Dr Simon Barton

The Clinical Reference Group (CRG) for HIV will be a key component in the delivery of HIV treatment and care, and will be the main source of clinical advice to NHS England as it moves forward in its direct commissioning role for specialised services. In this month’s eFeature Dr Simon Barton, Clinical Director & Consultant Physician HIV/Genitourinary Medicine at Chelsea and Westminster Hospital and Chair of the HIV CRG, gives an update on progress in establishing the HIV CRG and looks at the opportunities and challenges ahead.

The HIV Clinical Reference Group (CRG) is one of 76 similar groups which are responsible for providing advice to NHS England on the commissioning of specialised services. Over the past 18 months the CRG has scoped the nature of HIV specialist care, developed and consulted on a detailed service specification and defined quality outcome indicators that will be used in commissioning by Area Teams to ensure that standards set out in the national service specification are met.

The HIV CRG brings together specialist clinical expertise and public health advice with the views of patients and carers. Earlier this year the process of selecting new members for the CRG was started and much progress has been made: 14 clinical representatives, each with a geographical responsibility for providing advice, guidance and ensuring standards of HIV specialised care are met, have been appointed; four specialist professional associations have been nominated to represent the important roles of education, training and research in the provision of specialist HIV care; and four patient and carer representatives are soon to be appointed, to provide the invaluable patient and service user perspective. Details of membership are listed in full below.

Although the HIV CRG, along with other CRGs, has a clear remit and mandate to advise NHS England and guide the effective commissioning of specialised care, there are still many local issues to be resolved. For example, it is not clear what the role of clinical senates will be and there are still major uncertainties as to how the future provision of sexual health services, now commissioned by local authorities, will impact on rates of HIV diagnosis, particularly given the public health priority of avoiding late diagnosis. The HIV CRG is maintaining a close scrutiny of all changes as they occur across the country and keeping track of any effects that this may have on HIV specialist care. It is vital that all of the major initiatives and investment in sexual health services to increase the rate of early diagnosis of HIV and avoid HIV inpatient admissions is nationally co-ordinated. In this regard we are very much looking to work with Public Health England and have co-opted Professor Jane Anderson and Dr Valerie Delpech to the CRG to ensure close collaboration between Public Health England and the work of the HIV CRG.

Also critical to the future of HIV specialist care is the ability to collect epidemiological data on people living with HIV. To this end the new HIV and AIDS Reporting System (HARS) developed by the former Health Protection Agency (now PHE) will enhance the standard of HIV surveillance and provide outputs that will inform the accurate commissioning of HIV inpatient and outpatient services. This is particularly important in view of the new HIV outpatient tariff that will require an auditable assessment of the complexity of each patient’s care to determine the level of tariff paid.

It is clear that one of the reasons why specific services such as HIV Specialised Care were not allocated to Clinical Commissioning Group (CCG) control is the ability to make efficiencies in the national cost of the service as well as assure a national standard for HIV and other services that require specialised work forces and, in the case of HIV, have major public health implications. For example, the national or regional procurement of antiretroviral therapy (ARV) may be able to reduce costs of ARVs, thus maintaining more patients on effective therapy for the same budget. A similar approach to specialised pathology tests may also have particular efficiency advantages.

There is also a drive to reduce the number of services directly holding contracts by increasing network provision of HIV specialised care, thereby reducing the costs of managing contracts with several HIV service providers. This will be done through a process of derogation starting in October, where the national service specification will be held up against the current provision of services in relation to such things as 24/7 consultant on call for emergencies, and the provision of essential parts of specialised care such as pharmacy and adherence support. This will hopefully produce greater collaboration between units and, shaped by local commissioning, ensure that equitable services are provided wherever patients attend. It should also include access to research trials, up to date information and on-going support to provide effective self-management. Overall, this will reduce both the commissioning costs of services as well as optimise the efficiency of the care provided to a national standard.

It is a great advantage that in the new system, HIV has continued to be commissioned as a national specialised service. This, however, is not without challenge: not least to continue to provide, within a cost constrained NHS, evidence-based, safe and effective services for all HIV patients wherever they present and as locally accessible as possible. But, this is the goal the HIV CRG will be working to and the basis for the advice it will be providing to NHS England. It will be up to the Area Team Commissioners and the local CRG representatives to strive to achieve this and for the HIV CRG overall to ensure that it meets the national standard for the provision of HIV care and maintains the remarkable progress in diagnosing and managing HIV that this country has achieved in the past.

HIV CRG Membership Chair: Simon Barton

Responsible Commissioner: Claire Foreman

Clinical Representatives North East – Edmund Ong
Greater Manchester/Lancashire and S Cumbria – Ed Wilkins
Cheshire & Mersey - Mas Chaponda
Yorkshire & Humber – Christine Bowman
West Midlands – Stephen Taylor
East Midlands – Adrian Palfreeman
East of England - David Nelson
South West – Mark Gompels
Wessex – Cecilia Priestly
Thames Valley – Chris Conlon
South East Coast – Martin Fisher
London NW – Brian Gazzard
London NE – Ian Williams
London S – Derek Macallan

Professional Organisations
British HIV Association (BHIVA) – Duncan Churchill
British Association for Sexual Health & HIV (BASHH) – Simon Edwards
Children’s HIV Association (CHIVA) – Fiona Thompson
National HIV Nurses Association (NHIVNA) – Eileen Nixon

Patient and Carer Members
4 currently being recruited

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