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New challenges and new opportunities
For those of us who are concerned about how HIV services are commissioned, change is upon us. The NHS Plan, the National Strategy for Sexual Health and HIV, the abolition of the special funding allocation for NHS services, and the devolution of commissioning responsibility to primary care trusts, will all bring HIV services abruptly into the mainstream of the NHS. It is important that clinicians, managers, people with HIV, and all others with an interest in HIV services understand that it is not simply that the rules have changed; rather, we are now playing a different game altogether.
Historically, providers and commissioners of HIV services have had a number of benefits not available to many other parts of the NHS: dedicated money, a relatively high political profile, an articulate and well organised lobby from people with HIV and voluntary organisations, and identified commissioners with personal commitment to HIV and the time to focus on the development of services. Under this protective carapace, many services have flourished, and many people with HIV (though not all) have access to excellentsupport from their treatment centres.
The start of the current financial year on 1 April 2002 brought in at the same time a series of fundamental changes to the arrangements. The NHS no longer receives any money that is formally identified by the Department of Health as required to be spent on HIV, whether prevention or treatment and care. Instead, HIV services have to be funded from the main funding allocation to the NHS, all of which is channelled through primary care trusts (PCTs).
The skewed distribution of HIV across the United Kingdom means that many of the 301 PCTs in England have very few people with HIV living in their area, and HIV is not routinely cited by primary care as a priority. The 28 strategic health authorities have a broader geographical spread, but do not control any revenue funding; their performance management role is concentrated on NHS Plan targets, only one of which relates to HIV (“To implement the National Strategy for Sexual Health and HIV, once issued”). The Action Plan for the National Strategy issued in July 2002 offers exhortation but little active requirement.
The HIV commissioner (perhaps thankfully) is now an endangered species. Increasingly, this role is subsumed within a broader sexual health and/or specialised services role. This has a clear advantage in making sure that people responsible for HIV commissioning are exposed to the realities of priority setting in the wider NHS, but can lead to dilution of expertise and of ready familiarity with the issues faced by HIV services.
Regional specialised commissioning groups (which outside London are no longer co-terminous with the regional structure for the NHS, based in the four directorates of health and social care) are responsible for taking an overview of the commissioning of specialised services, including HIV treatment and care. Regional specialised commissioning groups bring together strategic health authorities and PCTs to agree priorities for specialised services. In London, the regional specialised commissioning group has supported the establishment of a commissioning consortium for HIV services, which has provided a welcome level of stability for providers and commissioners alike, and has minimised the bureaucracy of maintaining open access to care.
It is not simply that the rules have changed; rather, we are now playing a different game altogether
This series of changes sets a number of key challenges for commissioners and providers alike. We need to work intelligently with the new structures to ensure that HIV services meet agreed standards for care and are planned, commissioned, and delivered in a way that reflects the needs of the changing population of people with HIV in England. There are some basic steps that providers can take to equip themselves to play their part, including finding out how commissioning for HIV services is now organised in their area, and therefore who they need to influence. PCTs need to know how much of an issue HIV is for them, in both their provider and their commissioner roles, and how this will increase in the future, and NHS trusts hold much of this information.
For HIV prevention, we must work together to address the overwhelming capacity pressures in GUM services, to maximise opportunities for earlier diagnosis of HIV and appropriate STI management. This means more money, both revenue and capital, and requires commitment by PCTs (including those without a local GUM service) to prioritise these services and to plan collaboratively across a coherent catchment area.
For treatment and care services, we have to seize the opportunities presented by the national strategy, and define and introduce managed networks of care for people with HIV covering primary, secondary and tertiary care. Voluntary sector and local authority services need to be integrated into these arrangements. The networks must be standards driven, and must improve equity of access, so that all patients can access comprehensive high quality care. No HIV centre can on its own deliver all elements of care, nor should it attempt to do so.
In some areas, it may be relatively straightforward to agree who does what within the network, and where it should happen. Experience suggests that more often it may be difficult. In order to take this change forward, there has to be leverage, which can only exist where PCTs and providers are prepared to work together to sign up to a new model of care. Within London, this is being taken forward at sector level (each sector covering one of the five strategic health authorities) within a structure set by the London-wide HIV consortium and a bespoke HIV strategy for the city; this is a model that has much to commend it.
HIV services have an enviable reputation for their quality, and their ability to innovate. Developments in the care of people with HIV, spearheaded by the introduction of combination therapies, have transformed the prognosis for people who are diagnosed in time to benefit. Against this background, responding to organisational changes in the NHS should be a challenge that we can meet with confidence.
Admittedly, there is potential for trouble. Acute trusts and PCTs will need to be won over to developing and maintaining support for HIV services, in an NHS of centrally determined priorities and HIV as a local and growing financial pressure. Without influential champions for HIV services in providers and commissioners, the future could be distinctly gloomy.
However, if we can get our collective response right, the future can be bright. We should be able to secure services that are better planned and coordinated. HIV services should become less isolated from mainstream provision, and be prioritised for support based on an objective case of health need, and outcomes secured. This should result in services becoming more sensitive to the needs of their local populations.
Will Huxter was until July 2002 assistant director for specialised services, based at Islington PCT, and was responsible for commissioning HIV services in North Central London. He is writing in a personal capacity.
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