Agenda item

Dr Steve Hajioff, Director of Public Health, introduced an informational item detailing the tender for the new open access Integrated Sexual and Reproductive Health Service. Dr Hajioff was supported by the report author and Consultant in Public Health, Sharon Daye.

The Committee was advised of the background to the service, with sexual health a major public health issue. As part of the Health and Social Care Act 2012, responsibility for commissioning sexual and reproductive health services transferred to Local Government on 1 April 2013. The contracts for these services were held by three main providers: The Hillingdon Hospital (for the provision of genitourinary medicine services - 'GUM'); Central and North West London Trust (for the provision of contraception and sexual health services - 'CaSH'); and Hillingdon AIDS Response Trust (for the provision of prevention and support services for residents living with HIV and AIDS).

This had resulted in a disjointed service, with commissioning seen as a inefficient process. In addition, the contracts for these services were due to expire on 30 April 2017. A competitive tender exercise was therefore undertaken, to ensure a more cohesive service delivery that effectively met the current and future sexual health needs of residents.

A sexual health and reproductive health needs assessment had been undertaken in early 2016, which was used to inform the development of a transformed service model for the provision of open access, clinical, and non-clinical sexual health services. Parallel to the needs assessment, a number of meetings and events were held with the Business Improvement Delivery teams, external stakeholders, GUM and CaSH service users, as well as attendees at Children's Centres, to agree sexual and reproductive health pathways, and to consider the core values of the service alongside deliverables and outcomes.

Key challenges were identified as:

a)     High Risk Groups – under18s; adults at risk of STIs and HIV infection, or Black African men and women; Women in their twenties and thirties having abortions and repeat abortions; users of sexual health services who experience repeat STI infections.

b)     Vulnerable Groups – due to the setting or circumstances in which they live, or because of risks related to behaviour.

c)      Unreached Groups and Communities - finding access to service difficult due to stigma or other service limitations (e.g. LGBT groups), or at additional risk of exploitation because of life circumstances (e.g. people with mental health difficulties, learning difficulties, people with learning disabilities, victims of sexual assault or domestic violence and/or trafficking).

d)     Discontinuation of Long Acting Reversible Contraception –clearer understanding of the duration, variable uptake, removal rates of Long Acting Reversible Contraception (LARC) across the Borough.

e)    Early targeted prevention and intervention - keyto reducing the number of high need interventions, repeat attendances to GUM clinics and repeat abortions, to help to prevent high risk groups from developing more complex problems:

f)       Male service users - evidence suggests that young men are unlikely to actively seek out information or advice on sex. This needs to be addressed.

From reviewing the data, it was apparent that instances of STI's and repeat infections were rising in prevalence, particularly among young people. It was noted that the rate of under 18 conceptions continued to fall (i.e. 23.0 per 1000 female aged 15 to 17 years).

With regard to abortion levels, it was noted that 70% of teenage conceptions resulted in an abortion. The total abortion rate for those aged 15 to 44 years continued was continuing to rise.

The tender process commenced in September 2016, and two service providers completed and submitted tender responses. The Central and North West London NHS Foundations Trust (CNWL) and the London North West Health Care NHS Trust (LNWH) both adopted a 'prime provider' model, as specified by Hillingdon (i.e. one organisation held accountable for delivery of all services), and were assessed based on suitability, compliance, capacity, quality and value.

Following this assessment, LNWH was awarded the contract for the provision of the new open access 'Integrated Clinical and Non Clinical Sexual and Reproductive Health Services - including HIV Prevention and Support' for seven years (four years, with the option to extend for a further 3 years, inclusive of break clauses). The new model of service would offer rapid access to confidential, open-access, integrated sexual health services in a range of settings, accessible at convenient times, as well as providing improved quality and value. It was noted that the new service would be open access and therefore could be accessed by anyone, including those from outside of the Borough. It was confirmed that the London Borough of Hillingdon would only fund Hillingdon residents and that the new service providers would invoice the 'host' local authority of out of borough attendees to their services.

Services would be delivered on a 'hub and spoke' model, with the hubs likely to be in Uxbridge, whilst spoke clinics would be located across the Borough, to enable residents to access the service from all wards. Routine and intermediate services (level 1 & 2) would be delivered from all locations, whilst specialist treatment and care (level 3) would only be available at the hub.

The new service would provide a digital platform, allowing remote access to information and guidance to allow residents to 'self manage' their health, as well as 'self triage' including options for  home sampling for STIs and HIV, and the ability to book appointments. The system had been designed with ease of use in mind. Residents awaiting test results would be notified remotely (if negative), and advised to attend a clinic (if positive). Positive test results would not be communicated via text message. It was expected that self testing would also reduce the number of those residents who were asymptomatic and attending clinics, which would enable the 'face to face' service to focus on those people requiring treatment.

As residents can access services out of Borough, for which Hillingdon must pay, the new provider would be required to fulfil an invoice validation and payment service for out of area GUM/CaSH activity. It was anticipated that the new service provider would put subcontracting arrangements in place with primary care providers.

HIV treatment and care: Regarding interdependencies, NHS England is responsible for commissioning and funding HIV and outpatient treatment and care services. The provider of the new service model would be required to establish and maintain links with inpatient and outpatient HIV services within the Borough.

Post Exposure Prophylaxis after Sexual Exposure: PEPse drug costs would not be within the scope of the new service model. It is funded by NHS England in line with national arrangements. The new provider would therefore be required to bill NHS England for provision of these drugs.

PrEP: A Court of Appeal ruling in favour of the National AIDS Trust had set out that NHS England could legally fund the HIV prevention drug PrEP, and so NHS England was legally obliged to give consideration to the provisioning of the drug. This was now being trialled, though there was no timescale confirmed for a large scale rollout. NHS England was in the process of delegating commissioning work, with specialised commissioning likely to be moved to Clinical Commissioning Groups (CCGs), in approximately a year. The new integrated sexual and reproductive health service provider would not be commissioned by Hillingdon to provide PrEP. It was highlighted that NHS Scotland had started funding PrEP, and it was expected that NHS England would follow suit.

CCG's commission and fund abortion services. The new service provider would be required to maintain links with local providers to ensure the prompt referral of patients requesting abortion counselling. Cervical screening is the responsibility of NHS England. Routine, opportunistic and overdue cervical screens were all exempt from the new service model. CCGs would remain responsible for the commission and funding of gynaecology and menopause services, as well as psychology and sterilisation services. NHS England was responsible for the commission and funding of Adult and Paediatric Sexual Assault Referral Centre Services.

In summary, it was anticipated that the new open access service would provide greater flexibility and a high quality, robust service that would meet the needs of Hillingdon residents. In addition, the improved access and, geographical spread of services and increased opening hours would improve the residents' experience when using the services, in addition to providing greater value to the Council.

Members were supportive of the new service, and sought additional information via a number of questions. In response, officers confirmed that:

When non residents use Hillingdon services, the new service provider would invoice the 'host' local authority for payment. However, it was noted that rates charged outside the Borough were increasing, and a longstanding agreement not to charge non-residents more than residents was being removed. This was a potential financial risk which would be addressed by the new service  seeking to retrench outgoing delivery flows into Hillingdon via raising awareness about the new service and providing an accessible user friendly service which meets the varied needs of residents. As such, ensuring cost savings was paramount for the Council.

Abortions were seen to be increasing, though it was unclear why. It was possible that residents originally from certain countries, (including Eastern Europe) may be using abortions as a form of contraception, whistle for others the use of contraception services may not be viewed as appropriate. Further outreach and education (e.g. via schools), was necessary to help reduce these figures, focussing on changing behaviours and helping people to avoid putting themselves into high risk situations, such as parties where psychoactive substances were taken. Work is being undertaken with social media and providers of dating apps to include relevant health messaging.  However it was recognised that there was no easy solution.

When asked about the work of the new provider, LNWH, in neighbouring boroughs, it was confirmed that their service was being used in areas such as Brent, Harrow and Ealing. Prior to awarding the contract, detailed assessments had been undertaken using a broad set of data. Going forward, quarterly performance reviews, inclusive of KPIs and other performance measures, will be undertaken once the service is underway. Feedback will be sought from residents and used to make further improvements as the service progresses.

Regarding a start date for the new provider, a request was to be put to Cabinet requesting a short delay from the proposed 1 May start date. It was expected that this would push back the start date by a further two months, though this would not impact on costs.

Communications to advise residents of the new services would be undertaken, following internal mobilisation meetings. Discussions were being held around a unified communication across the Borough, to provide the service with a 'brand'. It was highlighted that the provider would be responsible for the bulk of the messaging, though Hillingdon would signpost and provide an overview. Avenues for informing the development of the new service's communications strategy will involve seeking the views of residents, including existing service users, speaking to members of youth parliaments, and other relevant groups. The Council's own Licensing teams (who had links to venues) would also be considered. In the past, bars and clubs had been receptive to helping communicate such messaging.

Brunel University's medical centre was suggested as a potential site for one of the service hubs. Officers confirmed that care had to be taken regarding procurement law and the sites required to be used as clinical centres. Conversations would be undertaken with the provider regarding additional sites, e.g. pharmacies, and this was expected to be formalised at future meetings.

Members thanked the officers for their report, and were pleased that such significant work had been undertaken to assess current service provision and ensure residents were better supported moving forward.

RESOLVED:  That the report be noted.