Sexual health commissioning - Frequently asked questions Published February 2013

Sexual health commissioning - Frequently asked questions Published February 2013
Health, adult social care and ageing
Sexual health commissioning
Frequently asked questions
Published February 2013
Sexual health commissioning - Frequently asked questions Published February 2013
Introduction                                      Thanks and acknowledgements go to the PHE
                                                  Sexual Health Assurance Reference Group:
These Frequently Asked Questions
                                                  Rashmi Shukla, Director of Public Health,
(FAQs) have been produced by the Local
                                                  PHE Transition Team
Government Association (LGA) and Public
Health England. They address a number             Justine Womack, Associate Director
of transitional issues relating to the transfer   of Public Health, DH SW and PHE TT
of responsibility for commissioning sexual        Andrea Duncan, Programme Manager,
health services to local government. The          Sexual Health and HIV Health, DH
LGA is producing a guide for elected
                                                  Judith Hind, Contraception Manager,
members and its Health and Wellbeing
                                                  Sexual Health Team, DH
Knowledge Hub group provides a forum
for people to share their challenges and          Chris Wilkinson, President, Faculty
solutions.                                        of Sexual and Reproductive Healthcare
                                                  Janet Wilson, President of the British
In addition to these FAQs the Department          Association for Sexual Health and HIV
of Health (DH) will shortly publish
guidance on local government’s mandatory          Simon Barton, Chair, NHS CB clinical
responsibilities for sexual health.               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
Sexual health commissioning - Frequently asked questions Published February 2013
What are local government’s                     Can local government
responsibilities for                            commission sexual health
commissioning sexual health                     services provided in
services from 1 April 2013?                     primary care?
There will be a number of commissioners         Yes. Local authorities can commission
responsible for commissioning different         sexual health services in primary care
aspects of sexual health services. From         although they are not responsible for the GP
1 April 2013 local government will be           contracted element of sexual health services.
required by regulation to commission HIV
prevention and sexual health promotion,         GP practices and community pharmacies
open access genitourinary medicine and          are key local providers of sexual health care,
contraception services for all age groups.      including some aspects of contraception
This includes services commissioned from        and Sexually Transmitted Infection (STI)
general practice and pharmacy as ‘local         testing and treatment. About 90 per cent of
enhanced services’, such as long acting         people’s contact with the NHS is with these
forms of contraception, chlamydia screening,    services. Most GPs, or their practice staff,
emergency hormonal contraception, sexual        offer basic contraception services as part
health aspects of psychosexual counselling.     of their general medical service or personal
This work will be led by specialised public     medical services contracts, which will be
health teams moving into local authorities.     commissioned by the NHS Commissioning
The NHS Commissioning Board and clinical
commissioning groups will commission            However, many general practices now
related services including:                     have staff, including practice nurses, who
                                                have undergone additional training to offer
• NHS Commissioning Board: HIV treatment        long acting reversible contraception and
  and care, health services for prisoners,      chlamydia testing as part of the National
  sexual assault referral centres, cervical     Chlamydia Screening Programme. From
  screening                                     1 April 2013, local government can
• clinical commissioning groups: community      commission these services directly. The
  gynaecology, vasectomy and sterilisation      whole cost of these services, including drug
  and abortion services.                        costs, will be transferred to local authorities.

General practitioners will be commissioned      Some areas have already agreed ways
by the NHS Commissioning Board to provide       forward. For example, the director of public
standard contraception services under the       health, on behalf of the local authority, has
GP contract.                                    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
Others are exploring subcontracting
arrangements with local commissioning                 Are local authorities
support units via clinical commissioning
                                                      responsible for
                                                      commissioning abortion
Can sexual health services                            services?
be jointly commissioned?                              No. Commissioning of abortion
                                                      services will be the responsibility of
Yes. Joint commissioning may enhance                  clinical commissioning groups. There
services by ensuring joined up                        is a national service specification
commissioning of services for the people              for abortion services, which sets
who use them. This might be undertaken                out recommended standards for
by different commissioning organisations              commissioning abortion provision,
such as local authorities and clinical                including the provision of all forms of
commissioning groups or a group of                    contraception, including long acting
neighbouring local authorities.                       methods, and testing for chlamydia
Where provider services are commissioned              and other sexually transmitted
by multiple commissioners, there may be               infections and HIV (if indicated by
a need for commissioners to collaborate to            local epidemiology). Clear clinical
ensure the service is viable and ensure no            pathways for referral to local authority
loss of service.                                      commissioned contraception services
                                                      and primary care services are important.
Lessons learned from commissioning to
date are that there can be economies                  It is anticipated that local government
of scale through joint commissioning.                 will wish to work closely with clinical
HIV and abortion services are two areas               commissioning groups to ensure that the
where collaborative commissioning could               full range of methods of contraception
particularly bring benefits for service users         are available at abortion services to
and for commissioning authorities.                    reduce the risk of repeat abortion and
                                                      further unwanted pregnancies.

Do sexual health services
                                                   of charge and services cannot be restricted
have to be open access                             only to people who can prove they live in the
and confidential?                                  area or who are registered to, or referred
                                                   by, a local GP or on the basis of age. More
Yes. Local authorities will be required by         detail is provided in the DH guidance on the
legislation to arrange for the provision of        mandatory functions regulations.
confidential, open access STI testing and
treatment and contraception services. This         The purpose of services being provided in
legislation will mean that anyone who is in        this way is to make it easy for people to be
an area, whether resident or not, is entitled      provided with contraception and testing and
to use the services provided in that area free     treatment for sexually transmitted infections

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

                               Sexual health commissioning Frequently asked questions (FAQs)     5
Do patients have to be seen                        absence of patient level identifiable data,
                                                   surveillance data can also be used to support
within a certain time frame?                       commissioning. In HIV, surveillance data
                                                   has been used to exclude duplicate activity
Yes. Rapid access to services is important,
                                                   and to analyse clinical outcomes. Local
to prevent unplanned pregnancy and to
                                                   government and public health teams will
ensure swift access to treatment for people
                                                   play an essential role in national surveillance
who have contracted an infection in order
                                                   for public health by requiring all contracts
to prevent complications and onward
                                                   with providers to include provision to collect
transmission of the disease. There are a
                                                   and supply mandatory data to relevant
range of situations where people need to be
                                                   organisations in the required form.
seen immediately. This can be to alleviate the
acute symptoms of an infection, to prevent         There are a number of mandatory national
an outbreak of disease where there may be          data collections for sexual health including:
multiple sexual partners, to prevent someone       Genitourinary Medicine Clinical Activity
contracting HIV by providing post exposure         Dataset (GUMCAD) for STIs, Chlamydia
prophylaxis following sexual or occupational       Testing Activity Dataset (CTAD), HIV and
exposure, or to provide emergency hormonal         AIDS Reporting System (HARS), all of which
contraception to prevent someone becoming          will be managed by Public Health England,
pregnant.                                          and Sexual and Reproductive Health Activity
                                                   Dataset (for contraception and other sexual
For other cases, rapid access to services
                                                   health care), which will be managed by
is still important to prevent the spread of
                                                   the NHS Information Centre for Health and
disease or unplanned pregnancy. National
                                                   Social Care. The majority of sexual health
standards are developed by professional
                                                   services have IT systems and software,
bodies including the Faculty of Sexual and
                                                   which facilitate extraction and communication
Reproductive Healthcare (FSRH) and British
                                                   of the necessary outcome and activity
Association for Sexual Health and HIV
                                                   data both locally and nationally. However,
(BASHH) and suggest that people should
                                                   these systems are less well developed
be offered a booked or walk-in appointment
                                                   for contraception and clinics should be
within 48 hours (two working days) of
                                                   supported to develop them. When drawing
contacting a service of their choice with
                                                   up contracts, local authorities will wish to
concerns about an STI.
                                                   consider the data they will need for their own
                                                   use and for national mandatory reporting.
Does local government
                                                   The role of the Health Protection Agency,
contribute to national                             the Health and Social Care Information
surveillance for public health?                    Centre and, Public Health England from 1
                                                   April 2013, is to contribute to protecting the
Yes. High quality information is central to
                                                   population from infection through routine
measuring sexual ill-health in order to identify
                                                   data collection and surveillance, modelling,
outbreaks and target high-risk groups, plan
                                                   epidemiological investigation, research and
services and monitor and evaluate initiatives
designed to improve sexual health. In the

6     Sexual health commissioning Frequently asked questions (FAQs)
Is one local authority allowed
     Local authority STI epidemiology
    reports (LASERS) can be requested
                                                                  to charge another authority
    from local HPA teams and include a                            if it provides sexual health
    table, listing for their residents the                        services to the second
    percentage of attendances by clinic to                        authority’s residents?
    assist with commissioning.
                                                                  Yes.Some people attend services that
                                                                  are not in their own local area. Some more
Do local authorities have                                         specialised services, may only be provided
responsibilities for clinical                                     on a regional or sub regional basis and
                                                                  require referral out of area.
quality and governance in
relation to sexual health                                         Arrangements between authorities must not
services?                                                         prevent services being open access or risk
                                                                  patient confidentiality.
Yes. The local authority as commissioner is
                                                                  There is already an approach for managing
responsible for commissioning clinically safe
                                                                  out of area payments for genitourinary
services. Sexual health services do carry a
                                                                  medicines services which is consistent
clinical risk, particularly some of the sensitive
                                                                  with confidentiality requirements. Providers
and invasive procedures performed in both
                                                                  invoice the patient’s PCT of residence
genitourinary medicine and contraception
                                                                  according to the care they received, using
services as well as safeguarding, medicines
                                                                  an agreed tariff price.
management and open access for non-
residents. To this end, they are required to have                 A non-mandatory genitourinary tariff will be
clinical governance arrangements in place.                        published for 2013/2014.

NHS services1 define clinical safety and                          Currently in the NHS, each service or clinic
governance in relation to the quality of care                     keeps records of activity, and invoices are
and it being effective, safe and provides                         prepared using mandatory Payment by
as positive an experience as possible.                            Results tariff prices. Commissioners currently
It recognises the patient journey cuts                            receive only limited data to verify activity,
across primary and secondary care, health                         identifiable or otherwise, in the form of an
and social care, and involves multiple                            invoice indicating cost. Partial postcode data
professionals and is a collective endeavour.                      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
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
No cross-charging and tariff arrangements          Are there any reasons why
currently exist for contraception or other
sexual health care, where most services are
                                                   people working in the field
provided under block contracts and PCTs            of sexual health are such
pay for all service users, regardless              advocates of the use of tariffs?
of whether they are residents or not.
                                                   Yes. The introduction of tariffs for sexual
Public health resources allocations for local      health was part of a range of measures
government were published on 10 January            to improve access to, and improve and
2013. Alongside this, the ACRA published           modernise, sexual health services, which
its responses to issues raised, including          led to significantly reduced waiting times
its view that cross-charging is the best way       for genitourinary medicine services and
to handle service use by non-residents             some stabilisation in rates of STIs. There is
applicable to sexual health.                       concern among the professional bodies that
                                                   these improvements will not be maintained
The use of cross-charging arrangements
                                                   if commissioners revert to the use of block
and tariff prices will not be mandatory for
local authorities.
                                                   The DH is currently considering how work
The Health Protection Agency provides
                                                   can continue on the development of a non-
information about flows of patients
                                                   mandatory tariff system for all sexual health
on its website at
                                                   services (both genitourinary medicine and
                                                   contraception), for local authorities based
                                                   on work already done by the London
Are there any restrictions                         Specialised Commissioning Group.
around what cross-charging
arrangements local authorities Is there a standard model
put in place?                            for approaching contracting
                                         of existing sexual health
Yes. While local authorities do not have
to use the non-mandatory genitourinary
medicine tariff and may decide to revert
                                                   No. The Department of Health, working with
back to a block contract, they must use
                                                   local government representatives and public
a contracting arrangement and payment
                                                   health professionals, has developed a public
mechanism that complies with the ‘open
                                                   health services contract for local authorities
access’ requirement of sexual health services
                                                   which reflects safe clinical practice and
being mandated. This may include funding all
                                                   processes. The contract is available at
patients that attend their local genitourinary
medicine service in addition to being cross-
charged by other local authorities.

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

                               Sexual health commissioning Frequently asked questions (FAQs)   9
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

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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