Another commissioning crisis – Sexual Health


A third of NHS contracts awarded since health act have gone to private sector, BMJ investigation shows

We were very concerned to read the BMJ investigation on NHS contracting, which reported that one third of NHS contracts were awarded to private providers and described ‘cherry-picking’ of simple procedures.1 Both the Royal College of Ophthalmologists1 and the British Association of Dermatologists2 have expressed serious concerns about threats to complex service provision, fragmentation of services and training.

Many of these concerns are also emerging in the sexual health and HIV service provision across England. These were not covered by this investigation as they are predominantly commissioned outside the NHS. We believe the quality, safety and future of these key clinical services are under threat, as a result of dysfunctional commissioning practices.

In April 2013, for the first time local authorities became responsible for commissioning services for sexual health, HIV prevention and testing. Treatment and care for HIV remained as a specialist service commissioned by the NHS and abortion services, after a brief period of commissioning by local authorities, became commissioned by clinical commissioning groups.

After a short moratorium local authorities in some areas started to procure sexual health services using tender processes. Since then our Association has received reports from its members across England about issues with commissioning, compromised patient pathways and fragmentation of sexual health services.

We are aware of models of contracting where the focus on cost efficiency appeared to override that of quality; where patient pathways, including those for complex sexual infections and specific groups, such as men who have sex with men (MSM), have been put at risk; and where postgraduate training has been seriously compromised because the service specifications have failed to take these requirements into account.

Some local HIV services have been de-stabilised and access to testing and treatment for sexually transmitted infections (STIs) for people living with HIV has been reduced.

Sexual health is a key clinical component of public health. A much higher proportion of adults in a local community are sexually active compared with those who smoke, are obese or have drug and alcohol problems. Overall, 1 in 5 adults will visit a sexual health clinic at least once in five years.3 Over 1 million HIV tests were performed in STI services last year, with a total of almost 450,000 new STI diagnoses recorded.4 Most STI services also offer HIV outpatient treatment, giving the UK one of the best performances in the world for retention of those diagnosed HIV positive into care, into treatment and to successful suppression of viral replication, thereby reducing transmission risk.5

We call for a strong national steer for co-commissioning of HIV, sexual health and reproductive health services.

Robust model contracting templates need to be used that recognise the requirement to deliver both basic and complex sexual health care, encompass specific groups, and retain seamless care from HIV testing into ongoing outpatient HIV care. Workforce development and specialist services of local relevance need to be contracted for alongside routine clinical care.

The clinical nature of the local authority contracts for sexual health needs to be recognised by sustained ring-fencing of resources. Sexual health does not feature in the NHS plan for sustained and protected funding. In fact, ring fencing of the public health budget will disappear in 2016/17 leaving services highly vulnerable.

We believe an investigation of the processes in local authority procurement exercises should be undertaken to reveal the extent of fragmentation of, and risk of damage to, one of the most important public health interventions we provide – clinical services to detect, treat and prevent HIV and other sexually transmitted infections.

We fear that a serious risk to public health is developing and urgent revision to the procurement process for sexual health is required to address these crucial issues.

1. A third of NHS contracts awarded since health act have gone to private sector, BMJ investigation shows. BMJ 2014;349:g7606.

2. Eedy DJ, Levell N. Dermatology decimated. 20 December 2014)

3. Sonnenberg P, Clifton S, Beddows S et al. Prevalence, risk factors and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal3). The Lancet 2013;382:1795-1806.

4. Public Health England (PHE). Sexually transmitted infections: annual data tables. London.… (Accessed 20 December 2014)

5. Public Health England (PHE). HIV in the United Kingdom: 2014 report. London.… (accessed 20 December 2014)

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