Commissioning challenges in sexual & reproductive health services

Leanne Bobb is a Commissioning Manager at the London Borough of Sutton. She has been the commissioner for sexual and reproductive health since April 2016 and previously was coordinator of the UK's first sexual health and contraceptive provider network, SWAGNET. Leanne is also one of the London representatives on the English Sexual Health & HIV Commissioners Executive Committee. In this eFeature, Leanne looks at the challenges that sexual health and reproductive health commissioners are facing in the current climate. She believes that adopting a whole systems approach to service commissioning is key to delivering innovative, high quality services and says this will require excellent working relationships across the system – commissioner to provider, commissioner to commissioner, provider to provider and organisation to organisation.

Sexual health and reproductive health services have come a long way since the transition of public health to local authorities. There are more integrated services across the country than ever before, which has been possible due the commissioning processes and regulations of local councils. Integrated services have combined both disciplines enabling patients to seek both STI screening, treatment and care alongside contraceptive health services all in one visit. Patient pathways and access to services through innovative ways of delivery have also improved. However, commissioners and providers are still having to battle with the fragmented commissioning arrangements that exist for different elements of care.

"One of the biggest challenges in my area of London is trying to work collaboratively with other organisations who have additional commissioning responsibilities for sexual health and contraceptive care. As recommended in the recent Health and Social Care Select Committee report on Sexual Health ‘in order to make sexual and reproductive health services more holistic, system mechanisms are required to support co-commissioning and joined up patient pathways’. It is vital that organisations work together to make services more cohesive, so that the care expected by patients is available to them, is convenient and is delivered to a high standard."

In Sutton, the Local Authority has changed its commissioning approach and has moved to a much more outcome-based focus. Commissioners from different areas across the organisation have come together in order to see if services going forward could be commissioned and delivered differently. By identifying where there is duplication and looking for better synergies or improved pathways, we can ensure we are spending public money in the best possible way but also focus on how services are more suited to the residents.

Locally, this also includes the development of the Sutton Health & Care Alliance, a partnership of our local GP Federation, Hospital Trusts including mental health and the Local Authority. The alliance works collaboratively in order to ensure that local people receive the care that they need in the right environment. Staff are employed and work within the partnership and each partner in the alliance has an equal say in decision making processes. The integrated sexual health service is delivered under this alliance via our local Hospital Trust. It is hoped through this arrangement we will be able to redesign how sexual health and contraceptive services are delivered in primary care settings.

Many other areas have already implemented different ways of delivering services using technology and data to really map effective ways to channel and shift demand in new and intelligent ways that are convenient, discreet and beneficial to the patient. More examples can be found in a new report by the Faculty of Sexual and Reproductive Healthcare (FSRH) launched in the November 2019 edition of the eBulletin. The report provides learning and case studies from areas innovating in the design and delivery of sexual and reproductive health services and embedding these services in new models of care.

Although it has been said that ‘austerity is over’, commissioners still need to manage the ever-growing demand of sexual health and reproductive health services within limited budgets, as well as ensure that services are not only financially viable but that providers are delivering value for money. In September, the Chancellor of the Exchequer, Sajid Javid, announced that there would be an increase in the level of funding to the public health grant. This is good news and is needed to provide vital services to the local community. However, the increase in funding is still down to local determination, therefore there are no guarantees that there will be more money available for sexual health and reproductive health services. Innovative ways of delivering services still need to be explored and executed.

In order to make further efficiencies, improve outcomes and maintain standards of care I believe a whole systems approach is needed. For example, it is acknowledged that some elements of care need co-commissioning, like cervical screening and PrEP. But there are other treatment and care pathways that sexual and reproductive health services could deliver that are not the commissioning responsibility of local authorities, but are recommended in BASHH or FSRH Clinical Guidelines. This would include complex chronic conditions, such as genital dermatology. Many patients would naturally attend a sexual health or reproductive health service when experiencing symptoms; however, due to funding arrangements, patients would have to be referred onto other services in order to seek the investigations that they may require. As with all services where there is a cross-over of commissioning responsibility, some areas will have good arrangements with different organisations and others have no provision whatsoever, meaning services become a postcode lottery. Sexual health and reproductive health services are open access and differences in provision should be minimal, so that patients know where to seek services and are less at risk of falling out of the system without receiving the care they need. Pathways for services should reflect the reality of the patient journey so that people are able to seek the treatment and care they need, easily and quickly.

NHS England, Clinical Commissioning Groups (CCGs) and local authorities need to undertake system reviews to ensure that local provision is meeting the needs of residents. This could be done via Sustainability and Transformation Partnerships (STPs) so that services could be provided over a larger geographical region, more holistically and really utilise the skills, knowledge and experience of clinicians no matter what area they work in, so that we can deliver the best care and services for residents. 

"I believe sexual and reproductive health still remains at the top of the agenda with many local authorities and other government organisations. The development of the new national sexual and reproductive health strategy, which will be led by the Department of Health and Social Care in partnership with other key stakeholders, should provide a revised and current framework for all of us to work to and strive to achieve. This can only work if we all remain passionate and driven to improve patient care. I personally have always felt extremely privileged to work for public services and want to do the best I can to make sure provision is delivered to a high-quality standard. This requires maintaining excellent working relationships - commissioner to provider, commissioner to commissioner, provider to provider and organisation to organisation. Having an attitude which is approachable so that stakeholders and colleagues feel comfortable to share is vital to making a whole systems approach work."

Originally published in the November 2019 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin. The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.