Good sexual health requires a whole system approach to commissioning

The progress achieved in the past 30 years in sexual health, reproductive health and HIV - or SHRHH - has been phenomenal.

Rapid, open access to high quality integrated genitourinary medicine (GUM) and sexual health services, together with improved choices for people’s reproductive health, have had an enormous impact on individual and population health and wellbeing.

‘Concerted efforts have reduced under 18 conception rates to the lowest level since the 1960s’

Concerted efforts across England have reduced under 18 conception rates by over 40 per cent since 1998 - the lowest level since the 1960s. 

And HIV - once universally fatal and killing people in the prime of their lives - now has the potential to be a long term, manageable condition.

• Acute trust takes on sexual health services
• Cambridgeshire Community Services wins second sexual health contract
• NHS England plans personal budgets covering NHS and social care

Keep at it

Yet in today’s world there is absolutely no room for complacency.

Rates of new, late and undiagnosed HIV infection remain unacceptably high, abortion rates reflect unmet contraception needs, and rates of sexually transmitted infections are stubbornly elevated.

We must ensure ongoing prioritisation of SHRHH across the entire health and social care economy to secure our gains to date and accelerate interventions to address ongoing challenges.

The past year has been a transformative time as the Health and Social Care Act moved from the statute book into the real world and responsibility for public health moved to local government.

At the same time, the economic climate and pressure on resources have required everyone to explore new approaches and opportunities that can deliver better outcomes and better value.

‘In today’s world there is absolutely no room for complacency’

Crucially the commissioning arrangements for SHRHH services have undergone radical changes. Local authorities, clinical commissioning groups and NHS England all have responsibility for some element of the patient pathway.   

Yet SHRHH is inextricably interlinked and service provision for all three is frequently co-located and provided by the same clinical teams.

Inextricably linked 

Changes in the commissioning arrangements for one area therefore have significant implications for the other areas.

With this in mind, it is clear that achieving outcome improvements and efficiency gains, requires a system wide approach to commissioning that champions integration, coordination and collaboration.

Progress is already being achieved in England.

‘A system wide approach to commissioning that champions integration and coordination is needed’

Those working within the system continue to evolve thinking and approaches in this unfamiliar world, and new partnerships are being forged between commissioning organisations, providers and communities.  

However, if population and individual patient outcomes are to be not just maintained, but improved it is essential that more is done to secure channels that enable new conversations with new collaborators.

To support our partners in this essential work, Public Health England published the report Making it Work: a Guide to Whole System Commissioning for Sexual Health, Reproductive Health and HIV.

The guide is designed to build on already available resources, focuses on how to establish seamless, integrated care pathways through a whole system approach, and describes how this can be made to work in practice.

The boundaries and interfaces between all the bodies involved in commissioning SHRHH services are explored, with advice on how to achieve effective partnership working. Considerations for delivering better value are also set out.

Practical public health tool

A wide range of stakeholders across the sector contributed to the development of the report. This includes 15 case studies that describe models of existing and emerging practice.

We hope these will provide valuable insights, not only for commissioners but also for providers, clinicians, patients and the public. 

We recognise that whole system commissioning for SHRHH is a substantial and complex task and that there will not be one correct way to do this. 

‘The UK has the best clinical outcomes for people living with HIV in the world’

Local areas will create the structures best suited to them through formal arrangements and other collaborative approaches. 

In doing this there is a real opportunity for commissioning teams to look beyond traditional boundaries and address wider determinants of good sexual and reproductive health. For example, by building stronger links with alcohol and drug misuse or mental health services.  

Commissioners will also wish to draw on the substantial expertise within primary care, for example in expanded HIV testing and reproductive health. 

However, while the priorities selected may be unique to each commissioning team, what is needed throughout the system is:

• a commitment to meticulous collaboration;
• an alignment of values and principles;
• an agreement on processes and mechanisms; and
• a willingness to work differently.

We will get there faster by sharing experiences of integrated working, and we hope the guide will facilitate making this a reality.

From the recent World AIDS Conference in Melbourne we learn that in 2012 the UK had the best clinical outcomes for people living with HIV in the world. 

This is a testament to integrated, coherent, collaborative, whole system working across boundaries and disciplines. 

We hope that the guide will be a practical aid to securing this “joined up” working within the new commissioning landscape, which will in turn deliver best SHRHH outcomes for the population of this country.

Professor Jane Anderson is consultant physician and director at the Centre for the Study of Sexual Health and HIV, Homerton University Foundation Trust. She was named one of HSJ’s Inspirational Women this year