Sexual health commissioning Frequently asked questions Published February Health, adult social care and ageing

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1 Sexual health commissioning Frequently asked questions Published February 2013 Health, adult social care and ageing

2 Introduction These Frequently Asked Questions (FAQs) have been produced by the Local Government Association (LGA) and Public Health England. They address a number of transitional issues relating to the transfer of responsibility for commissioning sexual health services to local government. The LGA is producing a guide for elected members and its Health and Wellbeing Knowledge Hub group provides a forum for people to share their challenges and solutions. In addition to these FAQs the Department of Health (DH) will shortly publish guidance on local government s mandatory responsibilities for sexual health. Thanks and acknowledgements go to the PHE Sexual Health Assurance Reference Group: Rashmi Shukla, Director of Public Health, PHE Transition Team Justine Womack, Associate Director of Public Health, DH SW and PHE TT Andrea Duncan, Programme Manager, Sexual Health and HIV Health, DH Judith Hind, Contraception Manager, Sexual Health Team, DH Chris Wilkinson, President, Faculty of Sexual and Reproductive Healthcare Janet Wilson, President of the British Association for Sexual Health and HIV Simon Barton, Chair, NHS CB clinical reference group for HIV Simon Bowen, Association of Directors of Public Health Jackie Routledge, North Lancashire PCT Claire Foreman, Assistant Director, North Western Division Simon Henning, Cheshire and Merseyside Sexual Health Network Director Paul Ogden, Local Government Association Paul Crook, Consultant Medical Epidemiologist, HPA London Ivan Ellul, NHS CB Sam Organ, PHE I&I Advisor Ann Sutton, NHS CB

3 What are local government s responsibilities for commissioning sexual health services from 1 April 2013? There will be a number of commissioners responsible for commissioning different aspects of sexual health services. From 1 April 2013 local government will be required by regulation to commission HIV prevention and sexual health promotion, open access genitourinary medicine and contraception services for all age groups. This includes services commissioned from general practice and pharmacy as local enhanced services, such as long acting forms of contraception, chlamydia screening, emergency hormonal contraception, sexual health aspects of psychosexual counselling. This work will be led by specialised public health teams moving into local authorities. The NHS Commissioning Board and clinical commissioning groups will commission related services including: NHS Commissioning Board: HIV treatment and care, health services for prisoners, sexual assault referral centres, cervical screening clinical commissioning groups: community gynaecology, vasectomy and sterilisation and abortion services. General practitioners will be commissioned by the NHS Commissioning Board to provide standard contraception services under the GP contract. Can local government commission sexual health services provided in primary care? Yes. Local authorities can commission sexual health services in primary care although they are not responsible for the GP contracted element of sexual health services. GP practices and community pharmacies are key local providers of sexual health care, including some aspects of contraception and Sexually Transmitted Infection (STI) testing and treatment. About 90 per cent of people s contact with the NHS is with these services. Most GPs, or their practice staff, offer basic contraception services as part of their general medical service or personal medical services contracts, which will be commissioned by the NHS Commissioning Board. However, many general practices now have staff, including practice nurses, who have undergone additional training to offer long acting reversible contraception and chlamydia testing as part of the National Chlamydia Screening Programme. From 1 April 2013, local government can commission these services directly. The whole cost of these services, including drug costs, will be transferred to local authorities. Some areas have already agreed ways forward. For example, the director of public health, on behalf of the local authority, has developed arrangements to contract with each individual GP practice. Others are commissioning the sexual and reproductive health services to contract with the GP practice and pharmacists so the local authority has only one contract to manage. Sexual health commissioning Frequently asked questions (FAQs) 3

4 Others are exploring subcontracting arrangements with local commissioning support units via clinical commissioning groups. Can sexual health services be jointly commissioned? Yes. Joint commissioning may enhance services by ensuring joined up commissioning of services for the people who use them. This might be undertaken by different commissioning organisations such as local authorities and clinical commissioning groups or a group of neighbouring local authorities. Where provider services are commissioned by multiple commissioners, there may be a need for commissioners to collaborate to ensure the service is viable and ensure no loss of service. Lessons learned from commissioning to date are that there can be economies of scale through joint commissioning. HIV and abortion services are two areas where collaborative commissioning could particularly bring benefits for service users and for commissioning authorities. Do sexual health services have to be open access and confidential? Yes. Local authorities will be required by legislation to arrange for the provision of confidential, open access STI testing and treatment and contraception services. This legislation will mean that anyone who is in an area, whether resident or not, is entitled to use the services provided in that area free Are local authorities responsible for commissioning abortion services? No. Commissioning of abortion services will be the responsibility of clinical commissioning groups. There is a national service specification for abortion services, which sets out recommended standards for commissioning abortion provision, including the provision of all forms of contraception, including long acting methods, and testing for chlamydia and other sexually transmitted infections and HIV (if indicated by local epidemiology). Clear clinical pathways for referral to local authority commissioned contraception services and primary care services are important. It is anticipated that local government will wish to work closely with clinical commissioning groups to ensure that the full range of methods of contraception are available at abortion services to reduce the risk of repeat abortion and further unwanted pregnancies. of charge and services cannot be restricted only to people who can prove they live in the area or who are registered to, or referred by, a local GP or on the basis of age. More detail is provided in the DH guidance on the mandatory functions regulations. The purpose of services being provided in this way is to make it easy for people to be provided with contraception and testing and treatment for sexually transmitted infections 4 Sexual health commissioning Frequently asked questions (FAQs)

5 When it comes to HIV testing, who is the responsible commissioner? Local authorities will be responsible for commissioning population-level services to prevent HIV and reduce late diagnosis. This will include all HIV testing programmes in sexual health and the commissioning of testing programmes in clinical and non-clinical settings. Other commissioners will however be responsible for clinically indicated HIV testing of individuals in acute settings and for other HIV screening programmes in clinical settings. For example, routine opt out HIV testing is undertaken in maternity services. Routine opt out HIV testing is also recommended in termination of pregnancy services, drug dependency programmes, and healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma. Clinically indicated testing of individuals will also be undertaken in a range of acute healthcare services. Testing in all of these scenarios will be part of services commissioned by Clinical Commissioning Groups or the NHS Commissioning Board rather than the local authorities. A collaborative approach is recommended to agree the most appropriate testing strategy for a local area, particularly in areas of high prevalence (2 in 1000 population) where evidence shows that it is effective to test all general medical admissions and new GP registrations. wherever they are. Good access to services prevents unplanned pregnancy (up to 50 per cent of pregnancies across all age groups) and the spread of infections and outbreaks of disease. STIs are infections that are spread primarily through person-to-person sexual contact. If untreated they can have critical implications for reproductive, maternal and newborn health and are the main preventable causes of infertility, particularly in women. Infection with certain types of the human papillomavirus can lead to the development of genital cancers, particularly cervical cancer in women. The presence of untreated STIs increase the risk of both acquisition and transmission of HIV by a factor of up to 10. Prompt treatment for STIs is thus important to reduce the risk of HIV infection. Controlling STIs is important for preventing HIV infection, particularly in people with high-risk sexual behaviours. Outbreaks of a range of infections can occur including syphilis, lymphogranuloma venereum (LGV) a sexually transmitted infection caused by chlamydia trachomatis, HIV, hepatitis B, hepatitis C and gonorrhoea. Standards of confidentiality over and above normal patient confidentiality are an important aspect of sexual health services to address the stigma associated with poor sexual health and encourage individuals to come forward for testing and treatment to prevent the spread of infections. This means that patients are entitled not to give their actual name, address or NHS number. It also means that information systems should enable confidentiality to be protected (ie not link up to other data systems that would enable them to be identified, whether local government or NHS). The Department of Health will publish further guidance on confidentiality this year. Sexual health commissioning Frequently asked questions (FAQs) 5

6 Do patients have to be seen within a certain time frame? Yes. Rapid access to services is important, to prevent unplanned pregnancy and to ensure swift access to treatment for people who have contracted an infection in order to prevent complications and onward transmission of the disease. There are a range of situations where people need to be seen immediately. This can be to alleviate the acute symptoms of an infection, to prevent an outbreak of disease where there may be multiple sexual partners, to prevent someone contracting HIV by providing post exposure prophylaxis following sexual or occupational exposure, or to provide emergency hormonal contraception to prevent someone becoming pregnant. For other cases, rapid access to services is still important to prevent the spread of disease or unplanned pregnancy. National standards are developed by professional bodies including the Faculty of Sexual and Reproductive Healthcare (FSRH) and British Association for Sexual Health and HIV (BASHH) and suggest that people should be offered a booked or walk-in appointment within 48 hours (two working days) of contacting a service of their choice with concerns about an STI. Does local government contribute to national surveillance for public health? Yes. High quality information is central to measuring sexual ill-health in order to identify outbreaks and target high-risk groups, plan services and monitor and evaluate initiatives designed to improve sexual health. In the absence of patient level identifiable data, surveillance data can also be used to support commissioning. In HIV, surveillance data has been used to exclude duplicate activity and to analyse clinical outcomes. Local government and public health teams will play an essential role in national surveillance for public health by requiring all contracts with providers to include provision to collect and supply mandatory data to relevant organisations in the required form. There are a number of mandatory national data collections for sexual health including: Genitourinary Medicine Clinical Activity Dataset (GUMCAD) for STIs, Chlamydia Testing Activity Dataset (CTAD), HIV and AIDS Reporting System (HARS), all of which will be managed by Public Health England, and Sexual and Reproductive Health Activity Dataset (for contraception and other sexual health care), which will be managed by the NHS Information Centre for Health and Social Care. The majority of sexual health services have IT systems and software, which facilitate extraction and communication of the necessary outcome and activity data both locally and nationally. However, these systems are less well developed for contraception and clinics should be supported to develop them. When drawing up contracts, local authorities will wish to consider the data they will need for their own use and for national mandatory reporting. The role of the Health Protection Agency, the Health and Social Care Information Centre and, Public Health England from 1 April 2013, is to contribute to protecting the population from infection through routine data collection and surveillance, modelling, epidemiological investigation, research and response. 6 Sexual health commissioning Frequently asked questions (FAQs)

7 Local authority STI epidemiology reports (LASERS) can be requested from local HPA teams and include a table, listing for their residents the percentage of attendances by clinic to assist with commissioning. Do local authorities have responsibilities for clinical quality and governance in relation to sexual health services? Yes. The local authority as commissioner is responsible for commissioning clinically safe services. Sexual health services do carry a clinical risk, particularly some of the sensitive and invasive procedures performed in both genitourinary medicine and contraception services as well as safeguarding, medicines management and open access for nonresidents. To this end, they are required to have clinical governance arrangements in place. NHS services 1 define clinical safety and governance in relation to the quality of care and it being effective, safe and provides as positive an experience as possible. It recognises the patient journey cuts across primary and secondary care, health and social care, and involves multiple professionals and is a collective endeavour. Is one local authority allowed to charge another authority if it provides sexual health services to the second authority s residents? Yes.Some people attend services that are not in their own local area. Some more specialised services, may only be provided on a regional or sub regional basis and require referral out of area. Arrangements between authorities must not prevent services being open access or risk patient confidentiality. There is already an approach for managing out of area payments for genitourinary medicines services which is consistent with confidentiality requirements. Providers invoice the patient s PCT of residence according to the care they received, using an agreed tariff price. A non-mandatory genitourinary tariff will be published for 2013/2014. Currently in the NHS, each service or clinic keeps records of activity, and invoices are prepared using mandatory Payment by Results tariff prices. Commissioners currently receive only limited data to verify activity, identifiable or otherwise, in the form of an invoice indicating cost. Partial postcode data or prescribing information, or GP registration is not identifiable and as such (following the principle of maintaining confidentiality) does not represent a serious breach. NHSmail or equivalent and password protection should always be used when supplying this information. 1 Quality in the new health system: Maintaining and improving quality from April 2013, a report from the National Quality Board (April 2013) Sexual health commissioning Frequently asked questions (FAQs) 7

8 No cross-charging and tariff arrangements currently exist for contraception or other sexual health care, where most services are provided under block contracts and PCTs pay for all service users, regardless of whether they are residents or not. Public health resources allocations for local government were published on 10 January Alongside this, the ACRA published its responses to issues raised, including its view that cross-charging is the best way to handle service use by non-residents applicable to sexual health. The use of cross-charging arrangements and tariff prices will not be mandatory for local authorities. The Health Protection Agency provides information about flows of patients on its website at Are there any restrictions around what cross-charging arrangements local authorities put in place? Yes. While local authorities do not have to use the non-mandatory genitourinary medicine tariff and may decide to revert back to a block contract, they must use a contracting arrangement and payment mechanism that complies with the open access requirement of sexual health services being mandated. This may include funding all patients that attend their local genitourinary medicine service in addition to being crosscharged by other local authorities. Are there any reasons why people working in the field of sexual health are such advocates of the use of tariffs? Yes. The introduction of tariffs for sexual health was part of a range of measures to improve access to, and improve and modernise, sexual health services, which led to significantly reduced waiting times for genitourinary medicine services and some stabilisation in rates of STIs. There is concern among the professional bodies that these improvements will not be maintained if commissioners revert to the use of block contracts. The DH is currently considering how work can continue on the development of a nonmandatory tariff system for all sexual health services (both genitourinary medicine and contraception), for local authorities based on work already done by the London Specialised Commissioning Group. Is there a standard model for approaching contracting of existing sexual health services? No. The Department of Health, working with local government representatives and public health professionals, has developed a public health services contract for local authorities which reflects safe clinical practice and processes. The contract is available at 8 Sexual health commissioning Frequently asked questions (FAQs)

9 The Department of Health has also prepared a narrative on contracts, which explained which of these should transfer and how commissioners and providers could discuss any variations to these contracts. The narrative also explained that where contracts had expired on 31 March 2013, commissioners would need to consider how these services should be commissioned in the future. Are local authorities responsible for funding postexposure prophylaxis drug costs following potential sexual exposure (PEPSE) to HIV? No. The NHS Commissioning Board holds the budget for antiretrovirals, which are used in preventing HIV infection as well as treating it. However, it is expected that local authorities will pay for attendance to genitourinary medicine services under the agreed contract arrangements and clinical commissioning groups will also do the same for accident and emergency attendance. The drug costs associated with PEPSE will be funded by the NHS Commissioning Board local area team. Post-exposure prophylaxis for potential sexual exposure to HIV consists of four weeks therapy with antiretroviral medication or highly active antiretroviral treatment (HAART). It is designed to address the window of opportunity to abort HIV infection by inhibiting viral replication following an exposure. Treatment needs to start as soon as possible and within 72 hours. Once initiated, it is necessary to complete a four week course of treatment. Given that, for optimal efficacy, PEPSE should be commenced as soon as possible after exposure, 24-hour access should be available. The Chief Medical Officer has endorsed and recommended open access PEPSE according to national guidelines. Accident and emergency departments (which will be commissioned by clinical commissioning groups), therefore, play a key role in risk assessing individuals, initiating PEPSE where indicated and referral on to genitourinary medicine for completion of treatment. This is undertaken with support and training from genitourinary medicine, HIV, infectious diseases or virology/ microbiology departments. Follow up will be undertaken within sexual health or HIV services. Are there prescribed arrangements for the strategic overview of sexual health services? No. Local areas will make their own arrangements. Health and wellbeing boards will look at the needs of their local populations based on an assessment of sexual health epidemiology and service provision and agree the strategy to address this in their area. Many areas already have sexual health networks and other forums and strategic groups in place that can feed into the Health and Wellbeing Board. In addition, clinical senates will provide a forum for clinical views to be heard. Sexual health commissioning Frequently asked questions (FAQs) 9

10 Is there a government policy document for sexual health being published soon? Yes. This is being led by DH and should be published shortly. It will also publish further guidance on confidentiality this year. Can local authorities commission voluntary sector services to provide HIV social support? Yes. There are many examples where third sector organisations have been commissioned to provide emotional and practical support to people who are already infected with HIV. Depending on the nature of the services provided, these may in future be commissioned by local authorities or in some cases (for example in conjunction with mental health services) by Clinical Commissioning Groups. These support services can have a positive effect on reducing onward transmission of HIV and supporting individuals to have a good quality of life and remain in employment wherever possible. There are many examples nationally, where third sector organisations have developed partnerships with local sexual health services to provide prevention information and resources to vulnerable/ hard to reach groups. These initiatives are important in supporting those at greatest risk, to reduce unintended pregnancies and/ or the transmission of sexual infections including HIV. 10 Sexual health commissioning Frequently asked questions (FAQs)

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12 Local Government Association Local Government House Smith Square London SW1P 3HZ Telephone Fax Local Government Association, March 2013 For a copy in Braille, larger print or audio, please contact us on We consider requests on an individual basis. L13-60

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