Commissioning for quality – what’s going well and what needs to happen next?

Posted 16 May 2024

Date: 16 May 2024

Author: James Woolgar

In this month’s eFeature, we hear about the work of the English HIV and Sexual Health Commissioners’ Group, from its current Chair, James Woolgar. He gives us some inspiring examples of what’s going well and explains what commissioners want to see from the next government.

The English HIV and Sexual Health Commissioners’ Group

The English HIV and Sexual Health Commissioners’ Group (EHSHCG) is a peer network run by commissioners, for commissioners. It aims to provide a strategic forum for those with commissioning responsibility for HIV, sexual health, and reproductive services, for improved population and patient-level outcomes in sexual health and HIV in England.

The EHSHCG provides an important space for commissioners to meet, network, and work together to improve the commissioning and delivery of integrated services and strategies locally. As well as this, the EHSHCG supports sector-led improvement by promoting and facilitating approaches to enhance and challenge commissioning practices for HIV, sexual health, and reproductive health services in England.

We now have a membership made up of 270 individuals, from across all regions of England. We represent our members through our local authority regional groups, supported by the UK Health Security Agency (UKHSA). We raise the voices and perspectives of public health and local government in these spaces, and always try to be systems- and solution-focussed.

Our Annual Report for 2022/23 summarises the areas of work that the group has recently contributed to. The group works across reproductive health, women’s health, and HIV, including pre-exposure prophylaxis (PrEP) and sexually transmitted infections (STIs).

Recent achievements

Members of the EHSHCG have been actively involved in contributing to the national HIV Action Plan and are members of the national implementation steering group (ISG). As part of this key strategic group, we help shape workplans and contribute key data, intelligence, and commissioner perspectives, to deliver action.

Last year, we commissioned vital insight work with communities, designed to understand the barriers to accessing HIV PrEP. A report on that research was published last year and has already been useful for commissioners, providers, and other stakeholders working locally and nationally.

As local authority leads, we have also worked closely with excellent service providers to roll-out routine commissioning of PrEP and have seen the success of this initiative in many areas. Despite this, PrEP access equity remains an issue in multiple localities, and there is always more work to be done.

We are also a key partner on the Advisory Group on Contraception (AGC), ensuring that commissioners’ perspectives are fed in, and that we are part of the ongoing approach to improve access and equity around contraception. This has included research focused on uncovering the access experiences of the most marginalised groups, who are often under-served by health and care services.

As an Executive Committee, we also made significant contributions to the Women’s Health Strategy and its action plans, and supported services in their response to the mpox outbreak.

What’s going well in local government commissioning

Our online forum and sharing space make us unique. All our 270 members can share and learn from each other about best practice and innovation in commissioning and service delivery.

We’ve seen great examples of innovation since commissioning of sexual health services moved to local government. There is more emphasis on accessibility, with clinical services offering longer opening hours and weekend opening. There has also been an increase in innovation around rapid diagnostics. Further examples of that best practice are shown here in Local Government Association (LGA) guides: How councils are driving innovation through partnership working.

Digital innovation has also had a huge impact, enabling people to order test kits and contraception online. We have commissioned online services, and we’ve focused on shifting services to where people live, taking clinics out of hospitals and into the community. For example, in Leicester, a new clinic was opened in a shopping centre, normalising sexual health by moving services into a community-focused location. Bristol have also done some fabulous work engaging under-served groups by using vending machines for test kits in key settings.

There has been a lot of thoughtful work around outreach provision to under-served groups, with different types of testing, and culturally sensitive messaging, tied to public health research on what works. Public health leads have been involved with providers and academic leads to understand what works and reduce barriers to healthcare. A number of areas such as East Riding in Yorkshire, and my own area in Liverpool, have seen sexual health go mobile. Liverpool’s ‘Sexual Health on Wheels/SHOW’ bus is getting out there and running clinics in communities that we struggled to get to before, working with community leaders to help engagement.

Around sexual health generally, I think we’ve done a good job of thinking strategically. We have been able to work across systems on sector-led improvement and peer review, and many areas have produced area-based strategies using a population health approach. Being based in local government means we are able to work effectively with other council departments and services, whether that’s with health visitors, social care, or children and young people’s services. We can work with colleagues on the wider determinants of health that impact people’s lives, and thus their sexual health.

We have been able to commission domestic abuse workers in clinics, worked with children’s services on addressing harmful sexual behaviours in ways that link with clinical, safeguarding, and sexual assault services, and supported adult social care providers around addressing stigma for our ageing HIV population.

It’s not just about commissioning, it’s about responding to local needs, and acting as the glue that binds many of the ambitions of the wider sector.

Commissioning of HIV and sexual health services was brought into local government for a reason, and that’s to focus on the prevention of ill-health, and wider determinants. We are ideally placed to look at this and be evidence-based and needs-led.

All that said, we share some of the same views as others across the sector at present, that some of the indicators are not going the way we want them to, and that we need clear national strategic direction and future-proofing of services. There are clear issues that need addressing to help us innovate further, and to work with our excellent providers to shift the dial on some of the current national figures.

Between 2012 and 2022, there was a 36% increase in consultations at sexual health services (now to over 4 million consultations nationally), and they are being delivered for £200 million less than before. We know we are providing value for money, but greater investment is required to ensure we can kick on. Our services are doing a really good job and if they were backed by better funding, just think what we could achieve. We are therefore working with the sector, Local Government Association (LGA), Association of Directors of Public Health (ADPH), British Association for Sexual Health and HIV (BASHH), British HIV Association (BHIVA), and the Faculty of Sexual & Reproductive Health (FSRH) to make a call to any future government. Our calls also back and endorse many of the existing FSRH Hatfield Vision principles.

Our call to action for the next government

We’re working on a manifesto with key areas we want the next government to focus on and we hope to publish that soon. These are the areas we’re looking at:

1.     We want a solid national direction of travel. We’ve had a HIV Action Plan, and a Women’s Health Strategy, but we haven’t had a Sexual Health Strategy, which is of urgent necessity.

2.     Once we have a national strategy with clear direction, we then need adequate funding to deliver it. Funding and sustainability for services is key, with some restoration of the public health grant.

3.     Shared quality standards and key performance indicators will be important, and they must be developed with the involvement of all partners.

4.     We want to see even more of a push for technology and innovation where needed. All areas should be served by digital transformation, hybrid and online offers, as well as the latest treatment developments.

5.     A consistent and centrally funded workforce plan will be so important to delivery. Workforces make this all happen and we fully recognise the need for a sustainable, professional, and diverse workforce.

6.     Robust prevention and outreach. Outreach has been a success in many areas, but because of the lack of funding and sustainability, many areas don’t have the ability to do what they want to do.

As a group, we want to continue to work with our vital national bodies to improve sexual health outcomes in the future, and to continue to support commissioners to deliver the best possible care and sexual health and wellbeing that we can, for the population. That’s what we’re all about.

The EHSHCG is supported by funding from local authorities and secretarial support from the Association of Directors of Public Health.

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