Sexual health commissioning - Frequently asked questions Published February 2013
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Health, adult social care and ageing 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
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
Board.
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) 3Others are exploring subcontracting
arrangements with local commissioning Are local authorities
support units via clinical commissioning
groups.
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) 5Do 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
response.
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
information.
1 Quality in the new health system: Maintaining and improving
quality from April 2013, a report from the National Quality
Board (April 2013)
www.dh.gov.uk/health/2013/01/quality-health-system/
Sexual health commissioning Frequently asked questions (FAQs) 7No 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
contracts.
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
www.hpa.org.uk/stiannualdatatables
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
services?
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
www.dh.gov.uk/health/2013/01/phs-contract/
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. http://tinyurl.com/cwjoync 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
services.
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) 9Is 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)
Local Government Association Local Government House Smith Square London SW1P 3HZ Telephone 020 7664 3000 Fax 020 7664 3030 Email info@local.gov.uk www.local.gov.uk © Local Government Association, March 2013 For a copy in Braille, larger print or audio, please contact us on 020 7664 3000. We consider requests on an individual basis. L13-60
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