HC 1048-III Health CommitteeWritten evidence from the Faculty of Sexual and Reproductive Healthcare (PH 182)

Executive Summary/Key Points

The Faculty of Sexual & Reproductive Healthcare (The Faculty) is a faculty of the Royal College of Obstetricians and Gynaecologists. The Faculty has a membership of over 14,000, with the majority of its members being general practitioners, the remainder being doctors working in the community in Sexual & Reproductive Healthcare. In early 2010 the Government created the new medical specialty of “Community Sexual and Reproductive Health”, to formalise the training of community based specialists in women’s health with a leadership role and relevant of public health training. The Faculty sets National clinical and service standards and awards competency based qualifications to specialists and GPs in the field of Sexual & Reproductive healthcare (SRH) which includes contraception, basic management of sexually transmitted infections, community gynaecological care.

Good sexual and reproductive healthcare is a public health challenge which has the potential to deliver significant public health savings, and therefore, should be a priority for both public health and the NHS, not least for the social and economic benefits it delivers.

The Faculty welcomes the proposal that community contraception and termination of pregnancy services will be funded as part of the ring fenced public health budget. Good sexual and reproductive healthcare is a public health challenge which has the potential to deliver significant public health savings, and therefore, should be a priority for both public health and the NHS, not least for the social and economic benefits it delivers.

The Faculty is concerned that the proposed division of commissioning pathways for SRH will lead to fragmented service provision for women’s health services which should be provided in a “continuum of care”.

The Faculty welcomes the principle of the “any qualified provider” tender basis for service provision in response to proposals for increased competition. This will ensure that services meet nationally recognised standards, are underpinned by a national tariff system of pricing, are delivered by staff educated and trained to nationally recognised standards, and are commissioned as part of a consultant led community network.

Commissioning in the past has been variable. The Faculty recommends that commissioning should be underpinned by nationally recognised commissioning guidance, quality standards and clinical guidelines. Sexual & Reproductive Health specialists should be involved in the commissioning process to help deliver improved patient related outcomes and service efficiencies.

Sexual ill health is not restricted by geographical boundaries, and therefore, commissioning must be equitable and consistent across coterminous local authority borders. This is particularly important in areas which are densely populated, and consist of multiple local authorities (eg London). Public Health England has a vital role to play in ensuring that this collaborative working is facilitated.

Sexual and Reproductive Health is linked to a number of public health areas, and therefore, Health and Wellbeing Boards must facilitate the development of local partnerships between providers to ensure that; efforts are not being reproduced or duplicated, local initiatives are mutually reinforcing and/or complementary to each other, seamless models of patient care are provided, and clinical and quality standards are being met across all providers.

Joint Strategic Needs Assessments will be crucial for the development of Local Joint Health and Wellbeing Strategies. It is vital that SRH services are included as key component in strategies, and that clinical leads working across sexual health services are involved in the development of these documents.

Arrangements For Commissioning Public Health Services

1. The Faculty welcomes the proposal that community contraception and termination of pregnancy services will be included as part of those services being commissioned and funded by the ring fenced public health budget.

2. Commissioning SRH services as part of the ring fenced public health budget managed by local authorities, will help ensure that fully comprehensive, sexual and reproductive health services are delivered across a range of health and community settings, and in particular, reach communities vulnerable to or at risk of poor sexual health, delivering the best possible outcomes for the local population as a whole. The centralisation of public health commissioning should also facilitate linkages between services for related public health issues. Around the country, many SRH services are forging links with related public health services such as those for alcohol, drug misuse, and social care, which are often linked to risky behaviour, unplanned pregnancy and poor sexual health (STIs). These combined approaches are more effective, help reduce duplication of effort, and offer better value for money for public health budgets.

3. Whilst the Faculty welcomes the proposal that SRH will be funded by the public health budget, there are concerns that the proposed commissioning structure may lead to fragmented service provision. As outlined in Healthy Lives, Healthy People, commissioning for community contraceptive services will sit with local authorities, whilst commissioning for primary care services provided in general practice will be carried out by the National Commissioning Board (NCB) via the GP contract. The Faculty is concerned that this division will lead to fragmentation of service provision with other women’s health services, which should be provided as a “continuum of care”.

4. The public health White Paper sets out that the process for NHS commissioning of public health funded activity will be “mediated by via a relationship between Public Health England (PHE) and the NHS Commissioning Board”. For SRH services, the Faculty recommends that there is a robust mechanism in place to ensure that effective, transparent dialogue is taking place between the NCB and PHE. Only then will we be sure that public health requirements are met, that negotiations take into account both clinical and public health expertise, and that services are not duplicated.

5. The public health White paper sets out plans to increase the range of providers for public health services. The Faculty is concerned about the impact that such increased competition may have on quality of service provision, and therefore, welcomes the principle of the “any qualified provider” rather than the “any willing provider” tender basis for community sexual health service provision, on the basis that this approach ensures that commissioners only commission those sexual and reproductive health services that:

Are underpinned by a national tariff system of pricing which is a true reflection of the services provided by sexual health services, and which will ensure a fair and level playing field.

Are underpinned by Faculty clinical and quality standards.

Are delivered by staff educated and trained to nationally recognised standards.

Are commissioned as part of a consultant led community network.

Are required to train in the medical specialty of Community Sexual and Reproductive healthcare (CSRH).

6. Commissioning of sexual health services has in the past been of variable quality. A 2008 Faculty Report on SRH services indicated that commissioners did not fully understand the services provided by community sexual and reproductive health clinics, the benefits they bring to the local population and the value for money they represent. It also found that in many cases, commissioners were not equipped with relevant knowledge and skills relating to sexual health. It is essential that clinical experts in the field of SRH are actively engaged in the commissioning process to help ensure both improved patient related outcomes and to help deliver service efficiencies.

7. Commissioning service specifications should also insist that national clinical and quality standards, such as those produced by medical Royal Colleges, medical specialties, and NICE, are adhered to. Such guidance is vital to ensure both consistency and quality across all services provided for public health purposes, and levers of accountability should be put in place to ensure this guidance is followed. There is a clear role for guidance and standards produced by the Royal Medical Colleges, Faculties and membership organisations to be utilised here.

8. Sexual ill health is not restricted by geographical boundaries, and therefore, commissioning must be equitable and consistent across coterminous local authority borders. This is particularly important in areas which are densely populated, and consist of multiple local authorities (eg London). Public Health England has a vital role to play in ensuring that this collaborative working is facilitated.

Arrangements for Funding Public Health Services (Including the Health Premium)

9. The Faculty supports competition that drives the standards of care up, however, it is concerned that increased competition could lead to a reduction in the quality of care provided. Whilst the any qualified provider approach may ensure that standards are met, the Faculty is concerned that potential new providers may ‘cherry pick’ the most lucrative services, and may not decide to provide training in order to keep costs down.

10. International evidence suggests that without a fixed tariff system in place, the resulting situation will be a “race to the bottom” to provide the lowest cost services at the most competitive prices, but potentially at the expense of quality of service provision. Clearly any compromise on quality could lead to rapidly worsening rates of sexual ill health, increased rates of unplanned conceptions, increased inequalities and ultimately, poorer health outcomes.

11. Recognising the inadequacies of the “block contract”, the London Sexual Health Programme has developed an integrated sexual health tariff. The publication of a national tariff system for sexual health, based on the work of the London Sexual Health Programme, which includes the core principles of patient safety, service quality, sustainability, cost-effectiveness, patient choice and open access, will ensure a level playing field for those bidding for contracts and will ensure that fully comprehensive SRH services, including those which provide training and development opportunities, are commissioned. It is also vital to ensure that in the future SRH services are adequately funded for the important public health work that they do.

The Structure and Purpose of the Public Health Outcomes Framework

12. The Faculty welcomes the underlying scope of the outcomes framework which is to reduce health inequalities. Teenage pregnancy is directly related to social deprivation, reinforces health inequalities, and is associated with significant avoidable premature mortality and ill health. The Faculty therefore believes that the proposed indicator relating to unplanned teenage conceptions will be instrumental in improving health inequalities. It will also be a vital tool in ensuring that all agencies involved in the prevention of teenage conceptions work strategically, in partnership and in collaboration, to achieve a joint goal.

13. However, the Faculty is concerned that the outcome approach may lead to a skewed allocation of scarce resources. Women of all ages need access to good sexual & reproductive health services, and there are other age groups which currently experience disproportionate levels of poor sexual and reproductive health: The UK faces the highest rate of abortion in Europe, and in 2009 17.5 in every 1,000 women aged 15 to 44, had an abortion, whilst 33 per 1,000, women aged 19, 20 & 21 had an abortion (Abortion statistics, England and Wales, 2009, DH).

14. Abortion is not only costly to the NHS, but research indicates that it is directly linked to deprivation. In Scotland, the abortion rate in the most deprived areas is double that of the rate in the least deprived areas (ISD Scotland Abortion Statistics (2010)). Reducing the number of unplanned pregnancies will have a direct impact on both deprivation and health inequalities. Whilst it is important that tackling teenage conceptions is a public health priority due to its relationship with health inequalities, it is vital that good, high quality sexual and reproductive health services are provided for all women of all ages.

Arrangements for Public Health Involvement in the Commissioning of NHS Services

15. Successful commissioning for public health services depends on a number of different factors relating to the availability and use of public health data and the skills to interpret it, the availability of best practice public health guidance which sets standards and expectations, and the development of clinical partnerships to share and draw upon expertise.

16. NHS commissioning for public health interventions should be underpinned by strong epidemiological research and needs-assessment evidence base. In 2008 a Faculty Report on SRH services highlighted that many PCT’s lacked detailed information about both the availability of Long Acting Reversible Contraception (LARC) provision in their area, and the availability of trained clinical professionals correctly trained to deliver LARC. This lack of data consequently led to a shortage of LARC trained clinicians across the country.

17. The Faculty recommends that in addition to taking public health advice from Local Directors of Public Health in local authorities, and from Public Health England, clinicians from different public health related specialties, such as SRH, should be invited to feed in to the NHS in the commissioning process for public health, to help ensure that the services being commissioned are both appropriate and of a high quality standard. This is particularly important for SRH, 80 per cent of which is provided in Primary Care General Practice.

18. NHS commissioning of public health services must also reflect other sources of guidance, such as those produced by the National Institute for Health and Clinical Excellence (NICE) for public health issues, future NICE Quality Standards, and for SRH more specifically, standards produced by the Faculty of Sexual & Reproductive Healthcare. Such guidance is vital to ensure consistency and quality of care, and levers of accountability should be put in place to ensure such guidance is followed.

The future of the Public Health Workforce (Including the Regulation of Public Health Professionals)

19. Medical Royal Colleges and Faculties are the gate keepers of postgraduate specialty curricula, and develop training programmes that are underpinned by national clinical and quality standards, and set within overarching governance frameworks. The Faculty has developed national standards and training programmes, in sexual and reproductive health, which are recognised as the Gold Standard.

20. In early 2010 the Government created the new medical specialty of “Community Sexual and Reproductive Health”, to formalise the training of community based specialists in women’s health with a leadership role and relevant of public health training.

21. Training and ongoing education is essential to achieving high quality and safe care which ultimately delivers cost savings for the NHS. For SRH, such cost savings lie in ensuring that a full choice for contraception is offered to all women. Many contraceptive devices, such as LARCs, require specific training to be able to fit them. Evidence shows that without properly trained clinicians to fit, follow-up, and reassure women about their contraceptive method, women often do not continue with their contraceptive method for long enough for the NHS to realise savings associated with them. Furthermore, incorrectly implanted LARCs can result in complications and premature discontinuation of use.

22. The Faculty is concerned that providers will not offer appropriate development opportunities and training unless mandated and funded to. Clearly, a service which trains is more expensive than one which is limited to service delivery and, in a competitive market, will be attractive to commissioners looking to control budgets. A proliferation of non training service providers will lead to a reduction in the quality of education, professional expertise, and the standard of patient care delivered. Provisions must be put in place to ensure the protection of good quality education, training and research and to ensure that all providers are subject to the same requirements.

23. “Developing the healthcare workforce” set out proposals to replace deaneries and professional advisory bodies for training, with an overseeing board called Health Education England (HEE). The current system of postgraduate medical training under the umbrella of the Deanery structure is highly effective, and therefore, the Faculty is concerned about the lack of clarity on how the HEE will undertake its responsibilities and who will perform the work currently carried out by deaneries.

24. Meanwhile, the training functions provided by Strategic Health Authorities (SHAs), which are currently responsible for the majority of training and education commissioning, will be replaced by new local skills networks. Further clarity is needed about the constitution of the proposed local skills networks, and the advice and input that they will receive from medical specialties.

25. Effective workforce planning is dependent on the provision of consistent, high quality workforce information. In the past, there has been a lack of robust SRH workforce data to highlight skills shortages and training needs. Robust reporting mechanisms must be put in place to ensure the collection of comprehensive workforce and needs assessment data which will help ensure that we have a workforce capable of meeting the future challenges of the NHS.

26. Healthcare providers will also need support in understanding their training needs, and HEE along with local skills networks will have a significant role to play in providing this. However, the extent of HEEs powers, and its relationship with skills networks, are currently unclear and require further clarification.

The Future Role of Local Government in Public Health (Including Arrangements for the Appointment of Directors of Public Health; and the Role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

27. Joint working and communication, is fundamental for the delivery of sexual health care that is comprehensive, avoids duplication, meets high standards, is clinically safe, and cost effective. SRH, which is provided across a range of settings (primary care, community, schools etc) and by a variety of providers, is also inextricably linked with a number of areas of public health such as alcohol and social care. Moreover, the new “Early Intervention Grant”, which will be allocated to local authorities, will also play an important role in funding a variety of initiatives to support a reduction in teenage conceptions.

28. With so many different groups, stakeholders, commissioners, funding streams and agencies working to achieve similar goals, it is vital that effective and transparent dialogue is facilitated to help build effective partnerships across localities, to ensure that efforts are not being reproduced or duplicated, that different initiatives are mutually reinforcing and/or complementary to each other, that seamless models of patient care are provided, and to ensure that clinical and quality standards are being met across all providers.

29. Joint Strategic Needs Assessments will be crucial for the development of Local Joint Health and Wellbeing Strategies. It is vital that sexual and reproductive health services are included as key component in local strategies, and that clinical leads working across sexual and reproductive health services, as local leaders in their field, are involved in the development of these documents.

30. Sexual ill health is not restricted by geographical boundaries, and therefore, commissioning must be equitable and consistent across coterminous local authority borders. This is particularly important in areas which are densely populated, and consist of multiple local authorities (eg London) consideration must be made of the appropriate level at which public health decision making operates.

The Faculty of Sexual and Reproductive Healthcare is a faculty of the Royal College of Obstetricians and Gynaecologists. The Faculty awards qualifications in sexual and reproductive health care and oversees specialty training in Community Sexual & Reproductive Healthcare. As a body it promotes conferences and lectures, provides a clinical advisory service and publishes the Journal of Family Planning and Reproductive Health Care. It has a membership of over 14,000, the majority of whom are general practitioners and includes consultants in the specialty of Community Sexual and Reproductive Healthcare and nurses working in SRH.

June 2011

Prepared 28th November 2011