NHS England is now looking at making changes to how 'specialised services' like HIV are commissioned. Depending on the approach they take, it could amount to what is effectively another restructure of the current system - but they aren't giving a lot of details.

This is a blog about NHS commissioning of HIV services in England.  If you aren’t already a massive commissioning nerd, you might want to take a quick look at our previous introductory blog on commissioning – and for more details on the technical stuff check out our site My Care My Voice.

We are now 18 months into ‘transition’, which is how people in the NHS describe the implementation of the Health and Social Care Act 2012 and the changes it has brought to commissioning in England.   For sexual health services (excluding HIV treatment and care), this has meant a transition in responsibility from NHS bodies (PCTs) to local authority commissioners.

The restructuring has been a process – things did not switch overnight on 1 April 2013 – and most people involved would readily admit it has been a difficult one.  There are still outstanding questions about how the new commissioning arrangements will impact services – especially for HIV, where prevention, testing, antiretrovirals and non-specialist hospital care are the responsibility of three different commissioning bodies.

There is one aspect of the new NHS landscape which has been working rather well, though:  the commissioning of HIV treatment and care services by NHS England.  It was agreed at the time of the Health and Social Care Act that a small number of specialised services should be commissioned at a national level, to ensure quality care for all and to prevent ‘postcode lotteries’.  Less than two years into the new system, however, it seems that this is already up for further change.

Services are considered ‘specialised’ if they meet the following tests:

• There are comparatively few individuals who require the service or facility
• There is a comparatively high cost of providing the service or facility
• There is a limited number of people able to provide the service or facility
• There would be financial implications for Clinical Commissioning Groups (CCGs) if they were required to arrange for the provision of the service or facility at a local level.

NAT has been clear from the start that HIV meets these tests, so we are pleased that HIV treatment and care falls within the scope of specialised services.  Antiretroviral drugs are still expensive, but the NHS can make significant savings if they are procured ‘in bulk’ by specialised commissioners.  In areas of lower HIV prevalence, even a small increase in new diagnoses could be destabilising to local health budgets.  The open-access nature of HIV clinics - and limited number of clinics across England – would make it very challenging for commissioners to identify whose care they need to pay for, and where they are accessing it.  It is simply more efficient to make these decisions at a national level.

Most importantly, it is a way of ensuring that people living with HIV have equal access to the best available treatment and care for their needs, wherever they live in England.  NHS England commissioners are advised by the HIV Clinical Reference Group, a group of doctors and patient representatives who recommend policies about treatments should be prescribed in which situations.  For example, in the past week NHS England released its policy on Dolutegravir, which will ensure rapid access to this new drug.  England continues to have amongst the best HIV treatment and care outcomes in the world.

NHS England is now looking at making changes to specialised commissioning.  Depending on the approach they take, it could amount to what is effectively another restructure of commissioning. 

All we know for sure (from NHS England documents) is that the vast majority of specialised services will in future be ‘co-commissioned’ with local CCGs.  This is also called ‘collaborative commissioning’, which is a slightly more descriptive term – but we have no details on what this will mean in practice. NHS England is yet to make a public announcement or publish an explanation of its vision for collaborative commissioning.  For now, we can only guess at what it might be mean HIV.

On the one hand, collaborative commissioning could be a good thing for HIV services, if it means that NHS England and CCGs will get together to plan better care pathways for people living with HIV.  It certainly can’t hurt for CCGs to get more involved in planning services for people living with HIV in their local area.

Another possibility is that (in addition to collaborative planning of services) the budget for HIV specialised services would be allocated to local areas and mingled in with the general CCG budget.  This would not be a positive step.  CCGs are autonomous bodies and a shared budget opens the door for blurred responsibility and possibly local variation in services provided to people living with HIV.

Collaborative commissioning could bring real benefits for HIV treatment and care - but also significant risks, depending on the model adopted.  If budgets move towards the local level it could represent a greater change for the commissioning of HIV services that anything we have experienced through transition. 

But right now, we simply don’t know.  The sooner NHS England opens up about the future of specialised services, the better.