1 Achieving cost effective delivery in
a devolved healthcare system |
1. The National Chlamydia Screening Programme
is a major Department of Health initiative, launched in 2003,
which aims to identify the sexually transmitted infection (STI)
Chlamydia trachomatis ('chlamydia'), treat those infected
and reduce transmission to others.
Chlamydia is the most common bacterial STI and is increasing in
young people under 25. Between 2004 and 2008 the number of young
people diagnosed with chlamydia in genito-urinary medicine clinics
rose by 14%, to more than 71,000. The infection can be easily
identified and treated, but if left untreated may cause severe
health complications including pelvic inflammatory disease, ectopic
pregnancy and infertility in women.
The probability of chlamydia infection leading to complications
is not well understood.
In November 2005 the Department appointed the Health Protection
Agency to oversee the Programme which is delivered locally by
the 152 Primary Care Trusts (PCTs) in England.
2. The Department does not know how much money
PCTs have spent on delivering testing and therefore cannot tell
whether the Programme represents value for money.
The Department allocated £150 million for the Programme to
PCTs between 2003 and 2009, but only £100 million is estimated
to have actually been spent on delivering the Programme.
The Department explained that many PCTs were facing financial
deficits between 2005-06 and 2007-08 and that the money had been
spent on other priorities, but accepted that it had no way of
tracing what these had been.
An estimated £42 million was spent on the Programme in 2008-09,
however, PCTs engaged more energetically with the Programme after
chlamydia testing was made a national priority.
3. The Programme is an example of the difficulties
which can arise when a national initiative is introduced into
a locally-managed NHS when influences and incentives for PCTs
are not adequately addressed from the beginning and all aspects
are locally commissioned, regardless of economies of scale. There
has been duplication of effort and cost in several aspects of
the Programme and the Department accepted that lessons should
be learnt from the Programme, in particular the need to be very
clear about what should be done at national, regional and local
level. Recent reports
by the Committee, including end-of-life care, tackling alcohol
harm, and autism, have provided evidence that PCTs often do not
have a good sense of what local need actually is, are not yet
good at commissioning and do not have the information to recognise
the costs and benefits of different services.
4. The costs of delivering a chlamydia test under
the Programme are highly variable between PCTs, indicating that
there is scope for efficiency savings. Savings of £40 million
per year could be made from 2010-11 if every PCT delivered tests
for £33, which the Agency estimates is achievable.
The Department accepted that the variations in cost were unacceptable
and committed to provide PCTs with a costing model, based on work
conducted by the National Audit Office and the Agency, to break
down their costs more easily and to benchmark themselves against
the kind of price shown in the model.
The Department had produced guidelines on costs when the Programme
started to be rolled out nationally in 2005, but it accepted that
there was now evidence of large cost variations which needed to
5. Following its launch in 2003, the Programme
was rolled out in three successive phases. All PCTs were commissioning
chlamydia testing under the Programme by March 2008.
The phased delivery of the Programme could have been beneficial
if lessons had been learnt along the way, however this only started
to happen some ten years after a screening programme had been
recommended by the Chief Medical Officer's report.
This meant that when PCTs increased their activity in response
to the Department's introduction of a target in April 2008, inefficiencies
in the Programme were multiplied, making it even more wasteful
of taxpayers' money.
6. Fragmented local purchasing led to a broad
range of prices being paid for equipment and services. Local areas
paid between 50 pence and £44 per test kit purchased in 2008-09,
and each local area developed its own IT system for the Programme
with prices varying from £1,000 to £100,000.
There was an opportunity to secure economies of scale by bulk
purchasing standard items for the Programme, but the Department
failed to put in place any national or regional procurement arrangements
and as a result money was wasted.
The Department is now setting up regional procurement hubs for
the NHS and committed to make dramatic improvements in procurement
and IT for the Programme.
7. PCTs acting individually also procure services
which support the Programme, such as marketing activities to encourage
young people to get tested, and websites which allow them to order
testing kits through the post. This has contributed to 45 different
local 'brand identities' being developed for the Programme.
The Committee heard evidence of a company which had approached
the Department and the Agency two years previously, offering to
provide a national website to allow young people to order tests
through the post, but was told to approach the 152 PCTs individually.
The Department acknowledged that a report on the Programme conducted
on its behalf by Dr Ruth Hussey and issued in November 2009 had
recommended that a national website should be established. The
Department said it would look at this very seriously.
8. The Department has not defined by how much
or by when the Programme should reduce the prevalence of chlamydia.
A model developed by the Agency in 2006 indicated that testing
26-43% of the 16-24 year old population could be expected to produce
a substantial reduction in the prevalence of chlamydia infection.
Taking into account all chlamydia testing under the Programme
and in genito-urinary clinics, an estimated 24% of young people
were tested in 2008-09, approaching the level where the Programme's
impact could be measurable.
However, the Department currently has no means to measure the
and needs to do so in order to gain an understanding of the cost-effectiveness
of the Programme.
The Agency has developed a proposal for a population-based survey
to monitor changes in chlamydia prevalence and is seeking funding
to implement this.
9. Unless young people are provided with advice
on safer sex and how to prevent infection when they are tested,
any reductions in the level of chlamydia infection will only be
sustained through continued high levels of testing and treatment,
which may not be cost-effective.
The Department acknowledged that it is vital that the Programme
is used to deliver advice to young people, pointing out that this
was a difficult client group to deliver such messages to.
10. In 2008-09, 88% of people who tested positive
for chlamydia were recorded as having received treatment, against
the Programme's standard of 95%. This means that an estimated
6,480 people who tested positive for chlamydia were not recorded
as having received treatment. Without treatment, testing is wasted
for the individuals concerned, since these people remain infected
and may go on to infect others.
The Agency acknowledged that it should aim to treat all people
who test positive, but said that over the life of the Programme
an average of 90% of people identified as positive had been treated
and that considering the difficulties in reaching young people
with this type of Programme, this was not a bad outcome. The Agency
had looked at the PCTs with the lowest treatment rates and considered
that the predominant reason was one of reporting treatment data
to the Programme rather than problems in getting people treated.
11. Most areas are not achieving the Programme's
standards for tracing and treating the sexual partners of people
who test positive. In 2008-09, nearly three-quarters of programme
areas (72%) failed to meet the Programme's recommended standards
for partner treatment.
Partners are very likely to be infected and failure to trace and
treat them means that the infection will continue to spread.
However, genito-urinary medicine clinics, which are outside the
Programme, also do not meet recommended standards for tracing
and treating partners. The Department acknowledged that some areas
needed to improve but said that contacting and treating partners
of infected people was a challenging area and that levels of partner
treatment were higher than those initially predicted by the Agency.
2 C&AG's Report, para 1 Back
C&AG's Report, para 1.1 Back
C&AG's Report, para 2.8 Back
C&AG's Report, paras 1.10 and 2 Back
Qq 40 and 41 Back
C&AG's Report, para 3.7 Back
Qq 60-64 Back
C&AG's Report, paras 1.2 and 2.9 Back
Qq 30 and 53; C&AG's Report, para 10 Back
Qq 9 and 54 Back
C&AG's Report, para 3.8 Back
Qq 39-41 Back
Q 11 Back
C&AG's Report, para 1.8 Back
Qq 10 and 11 Back
Q 87 Back
Q 24; C&AG's Report, para 3.10 Back
Qq 20-31 Back
Qq 19-31 Back
Q 45; C&AG's Report, para 3.11 Back
Qq 27 and 34-37 Back
C&AG's Report, Recommendation a(i) Back
C&AG's Report, para 2.5 Back
C&AG's Report, para 2.5 Back
Q 82 Back
C&AG's Report, para 2.5 Back
C&AG's Report, para 2.19, Recommendation b(ii) Back
Qq 14 and 15 Back
C&AG's Report, para 2.12 Back
Qq 48, 49 and 68-72 Back
A programme area may include more than one Primary Care Trust.
There are 91 programme areas and 152 Primary Care Trusts in England. Back
C&AG's Report, para 2.13 Back
Qq 65-67 Back