Sexual healthcare 'at risk from NHS changes'

Image caption The experts fear pursuing profit will skew health priorities

Many NHS services are being put out to tender - and private companies can bid.

In this week's Scrubbing Up, Dr Steve Taylor, a sexual health and HIV specialist from Birmingham Heartlands Hospital and Dan Hartland from the HIV awareness charity Saving Lives warn there are unique dangers in allowing them to run sexual healthcare.

Many people may be unaware that one facet of the government's health reforms allows private companies to tender to provide NHS services - including sexual healthcare.

Traditionally, such services have been paid for using an internal NHS tariff system which covered basic costs, but also factored in associated costs such as contact tracing partners and providing prevention messages.

The tariff does not cover the cost of treating complicated cases, such as secondary syphilis, but ultimately the mix of simple and complex cases balances the books.

However, as of April 2013 things will change.

'Envy of the world'

Many services are being put out to private tender - and will be overseen by GP-led Clinical Commissioning Groups (CCGs).

But CCGs will not commission sexual health or public health services such as obesity and smoking prevention.

This function will fall to local councils, and elected officials. The directors of public health who will advise on these decisions will need to be strong advocates for the disadvantaged and stigmatised.

HIV services, meanwhile, will be commissioned centrally by the NHS Commissioning Board.

This separation is fraught with difficulties: especially when both sexual health and HIV care are currently provided by the same healthcare professionals on the same premises.

It is similarly unclear who will pay for HIV prevention campaigns.

The reforms are therefore a challenge to the joined-up way of working we currently enjoy.

Over 85% of all people attending NHS sexual health clinics take up HIV testing, with referral and retention rates both excellent - resulting in world-class patient outcomes.

Currently, then, we are able to treat patients, map epidemiological trends [disease patterns in the population] and target our prevention campaigns in a manner which is the envy of the world.

Any private company tempted to bid for a contract from a local council, meanwhile, will have subtly different priorities.

'Untenable' services

There will certainly be a handsome profit to be made from delivering straight-forward tests for sexually transmitted infections and HIV.

But diagnosis, management and treatment of the more complicated cases or assiduous epidemiological data collection might not be such money-spinners.

Is the private sector willing to provide such expertise, to perform 'contact-tracing', the unique NHS service which helps us track the spread of pathogens and identify outbreaks?

The worried well are an easy market.

But will private companies really target the hard-to-reach populations who need the services most, such as prisoners, commercial sex workers and intravenous drug users?

The difficulty with splitting HIV service provision apart from sexual health provision will also begin to tell.

Relatively expensive HIV services may become untenable without the staff and stability offered by providing the two services together.

It would be so easy for the 25,000 people in the UK who do not know they have HIV to become 50,000 as a result of non-targeted testing and the demise of contact-tracing.

Now is the time that we should be deepening the links between prevention, research, treatment and care if we are to really make an impact upon silent STI (sexually transmitted infections) epidemics, teenage pregnancies and undiagnosed HIV.

Instead, there is a very real risk that currently joined-up services will become fragmented, with huge variation in service.

We must work with our public health colleagues, who will for the first time be part of local government rather than the NHS, to put pressure on local councils to prioritise high quality sexual health services amid demands from many disciplines for unallocated funding.

But which councillors will want to champion STI and HIV services, when promoting an already stigmatised area of healthcare may not win many votes?

And what will happen in areas where councillors with staunchly religious views are in control?

We need brave advocates amongst politicians, patients and doctors alike.

The current NHS sexual health and HIV services are far from perfect.

But we are sure that the government and the public alike will not know how good they were until things start going wrong.

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