HIV prevention and care, and sexual health services, are facing substantial reorganisation in England, with big implications for care. Tony Kirby and Michelle Thornber-Dunwell report.

On April 1, 2013, a major transition in health care began in England through the Health and Social Care Act. The reform included the abolishment of National Health Service (NHS) primary care trusts (PCTs), which oversaw services at a regional level, with their local commissioning powers transferred to the 220 groups of general practitioners, called clinical commissioning groups (CCGs). Sexual health services and HIV prevention (including HIV testing) was also transferred to the control of England's 353 local authorities (councils), who now find themselves negotiating directly with NHS and other providers to continue these services.

One of the potential problems of this break-up of HIV care from prevention is that sexual health or genitourinary medicine (GUM) is usually delivered in the same buildings and by the same teams as HIV care, and experts at both the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH) have raised concerns that the split will mean services that have taken years to develop could rapidly disintegrate, leading to deteriorating patient care, services, and staff training, while jobs and crucial in-house experience could be lost. “The previous UK Government under Tony Blair allowed PCTs to tender for services if they wanted to, but most preferred to keep services in-house”, says Janet Wilson, president of BASHH. “Those that did tender ran into problems, sometimes serious problems, and we are worried there will be more examples of damage to patient care as more local authorities put their sexual health services out to tender.” Observers think that most local authorities will tender for their sexual health and HIV prevention services in the next 2-3 years.

“Sexual health clinicians have been sounding warnings about the restructuring of sexual health since the full details of the government's health reforms became clear. Fragmentation of sexual health services, particularly the split in commissioning of GUM and HIV, was highlighted as an area of great concern for patient care and public health”, says Wilson. She highlights the lack of accountability in the new system if things go wrong. “Who will hold local authorities to account when services are fragmented, disrupted, and patient care falls below that which is mandated in law? Sadly, even with poor services, patients are unlikely to complain due to the stigma attached to STIs [sexually transmitted infections].”

Cracks appearing BASHH, along with the Royal College of Physicians, has just published its paper on key threats from tendering of sexual health services. And a recent survey by BHIVA found that of 100 HIV specialists questioned, a third thought care for people with HIV was poorer since the reorganisation, and two-thirds thought care was set to deteriorate further. Awarding the service to a new provider can cause problems in finding suitable clinic accommodation as has occurred in one sexual health and HIV service in the east of England. Another in the northeast no longer initiates partner notification on people newly diagnosed with HIV (the most effective way of diagnosing further HIV infection). Elsewhere, the city of Birmingham has begun putting all its sexual health and HIV prevention services out to tender, while in London, concerns were raised that some London boroughs might not fund post-exposure prophylaxis treatment. “My concern is that once the UK Government's ring fence around public health funds is lifted in 2016, councils may divert this money to other areas in their budget, such as social care”, adds Wilson. “To-date the biggest problems relating to split commissioning and de-integration of services have been in smaller towns and cities”, says David Asboe, chair of BHIVA. “More remote areas are under big threat because previously integrated HIV services may not be prioritised by local authorities, and secondly small HIV services are threatened with survival once the sexual health component has been relocated.”

Opportunities and risks London's Chelsea and Westminster Hospital NHS Foundation Trust is the UK's largest provider of sexual health and HIV services. “At the moment, the ability of patients to have HIV and sexual health screening anywhere they choose is being protected, while councils and health-care providers negotiate contracts for the future”, says James Beckett, the trust's general manager for HIV, sexual health and dermatology. Beckett highlights some positive opportunities in the new system such as the ability of providers and councils to work together to deliver particular packages at varying prices to boost screening in high-risk populations—including black-African populations and men who have sex with men (MSM), both of which are estimated to have higher rates of undiagnosed HIV. Postal testing is also emerging as a way to deliver HIV testing. Yet Beckett admits “there is nervousness about the future, and it's vital for patients that the ability of service providers to cross charge to the resident's local council is not put under threat”. Control of HIV prevention and testing has been transferred to local authorities Copyright © 2014 BURGER/phanie/Phanie Sarl/Corbis From a council perspective, demand for sexual health services is forecast to rise, in an environment of shrinking local authority budgets and fixed public health budgets. Thus there is a real risk that cost pressures from such demand-led activity could effect resources for sexual health. The notion of cross charging is a real financial risk for local authorities who commission local acute hospitals on block payment-by-results tariffs. Thus it is impossible for councils to forecast demands for payment from other sexual health clinics when this is contingent on demand from patients who, by law, can access these services anywhere. Lambeth Council, in central London, has the highest prevalence of HIV in the UK (14·4 per 1000 people). “There is a lot of work to be done when it comes to tackling HIV rates both in Lambeth and across London. The new funding arrangements have given us an opportunity to look at the issue again and develop new and better strategies”, says Jim Dickson, the council's Cabinet Member for Health and Wellbeing. “We are working with our neighbouring boroughs, Southwark and Lewisham, which have similar infection rates. Extra resources have been allocated allowing various activities including new research on the best way to stop new infections, particularly among MSM.” At the forefront of ensuring that the new environment is not detrimental to patients and services is Public Health England (PHE), a new agency established on April 1, 2013, by the new health legislation. PHE aims to protect and improve the nation's health and to address inequalities. HIV and sexual health are PHE priorities. “We are in a complicated new landscape, in which the pathway for HIV diagnosis, care, and prevention is commissioned by up to three different organisations—local councils, the NHS clinical reference groups, and CCGs”, says Jane Anderson, adviser on HIV, sexual and reproductive health at PHE. “We are very alert to the risk of fracturing of this pathway, and it is essential that all the parties involved work together in a meticulous, joined-up manner to maintain services and standards and improve outcomes.” PHE is currently preparing a new national framework for HIV and sexual-health care, that can be modified to local needs. The framework will be ready for consultation in the first half of 2014.

Care review Since April, 2013, the commissioning responsibility for HIV treatment and care has resided with NHS England where a single commissioning model is in place for specialised services. “Commissioners have an ongoing responsibility to work collaboratively across the whole pathway and across organisational boundaries to contribute to service reviews and monitor the impacts of proposed changes”, says Jess Peck, service specialist in the NHS England London Region. A London service review for HIV is underway, to determine the make-up of the service in the next decade. Various factors have driven the review, including the huge positive effect of antiretroviral treatment, which means that most patients (Wilson estimates 80%) are stable and otherwise healthy, needing less frequent hospital visits. “There is also a need to manage the risks of other long-term conditions and coinfections that require better integration between the HIV services, primary care, and other hospital services”, says Peck. Of concern, in terms of budget pressure, is the annual growth of 5% in service usage in London as a result of the increases in HIV infection. The HIV workforce must also be planned to ensure competencies and services are delivered according to need to ensure safety and cost efficiency. “Managing the risks of late diagnosis, which can predict HIV complexity, is also a key issue for the review”, adds Peck. HIV service reviews are also being arranged for other regions in England, but the review is a priority in London because around half the people living with HIV in England and accessing treatment and care are using London services. “Like other specialised services, we are having to seriously consider ways to get the best value for money where population growth is not matched by funding growth”, says Peck. Under consideration is the possibility of consolidating services into fewer larger clinics that have flexible access doors across the capital. “These larger services could afford better access to other specialist health services and allow the development of more robust pathways with primary care services”, says Peck. HIV drugs coming off patent could also reduce costs, she adds. The review is expected to make recommendations for public consultation during late 2014.