Agenda item

Purpose of the report:

To update the Adults and Health Select Committee on the performance of the Sexual Health and HIV Service contracts.

Declarations of Interests:

An interest was declared by Mr David Mansfield as a former employee of Central and North West London NHS Foundation Trust.

Witnesses:

Helen Atkinson, Strategic Director for Adult Social Care and Public Health

Helyn Clack, Cabinet Member for Health

Cliff Bush, Director, Surrey Coalition of Disabled People

Fiona Mackison, Service Specialist (Specialised Commissioning), NHS England

Mark Maguire, Service Director, Sexual Health and HIV Services, CNWL

Matt Parris, Deputy CEO, Healthwatch Surrey

Dr Clare Sieber, Medical Director, SSLMCs

Stephen Tucker, Deputy Service Director, Sexual Health & HIV Services, CNWL

Key points raised during the discussion:

1.     The report was introduced by the Cabinet Member for Health who highlighted that the aim of the integrated Service was to promote early intervention on sexual health and HIV in order to create capacity within the system to support those with more complex or advanced conditions. She acknowledged that there had been challenges during the first year of the contract while Central and North West London NHS Foundation Trust (CNWL) were implementing the integrated service but highlighted that she was confident that by moving some services online, the new provider would create more efficient sexual health and HIV provision. These comments were echoed by the Strategic Director for Adult Social Care and Public Health who provided Members with the background to the introduction of an integrated Sexual Health and HIV Service for Surrey. The Committee heard that work had begun on the introduction of an integrated service through development of the Sexual Health Needs Assessment (SHNA). The extent of the reductions to funding for Public Health in Surrey were not known when work had begun on the SHNA.

2.     The Strategic Director for Adult Social Care and Public Health apologised to those who had been left short or inconvenienced by the changes to which had occurred to Sexual Health and HIV Services in Surrey. Members were advised, however, that a phased approach to changes in the Service had been adopted to enable CNWL to better respond to concerns raised by patients and partners about the new model. Members were asked to recognise that there was a need to modernise the Service by making more effective use of the digital space and to understand that these changes took time to implement. Members were further informed that CNWL had been very flexible during this implementation phase in order to respond to the concerns of patients and stakeholders.

3.     The Committee heard from the Service Director who stated that CNWL already operated an integrated Sexual Health and HIV Service in London which was highly regarded by its patients. Members were asked to recognise the scale of the challenge that CNWL confronted in attempting to integrate and modernise the three very disparate and outdated service models that had existed in Surrey prior to the introduction of the new contract in April 2017. CNWL were legally prohibited from reviewing staff structures until the TUPE transfer from all three service providers had been completed which had prevented the Trust from introducing a modern staffing structure which had hampered CNWL in taking the necessary steps to implement the integrated Service. The TUPE transfer had happened in October 2017 and so Members were advised that the significant transformations to the Service would take place over the coming months. 

4.     The Service Director detailed some of the work that CNWL had done in order to bring the three sexual health and HIV services together since taking over the contract. Members were advised that a single provider had been contracted to provide pathology services while pharmacy services had also been brought together under one provider. A single patient record for those using Surrey’s Sexual Health and HIV Service had been introduced as well as a single website where people could book appointments and order online testing kits. An online contraception service would also be rolled out over the next few weeks.

5.     Representatives from CNWL recognised that problems had been encountered during the introduction of the new Service including with the online booking system which had caused disruption for those wishing to make appointments. Members were told, however, that both the telephone and online booking systems were now functioning at full capacity. It was further highlighted that there was a need to increase capacity across the Service and that this would take place over the following year in order to keep pace with demand. The Committee heard that CNWL was looking at methods to promote the Service, particularly among ‘at risk’ groups to ensure that people knew how to access the Service. 

6.     Attention was drawn to the results of the patient feedback survey undertaken by CNWL. Members acknowledged that the results were encouraging but asked what steps could be taken to get a broader range of opinion on the Service, for example, from residents who had chosen to go out of county for treatment in order to understand their rationale for deciding to access Services outside of Surrey. The Committee was advised that Sexual Health Services were open access meaning that people had a personal choice in where they sought treatment. A significant proportion of Surrey residents commuted into London and so it was more convenient for them to attend a Genito-Urinary Medicine (GUM) Clinic close to work. The Cabinet Member for Health indicated that the convenience of online services such as contraception and testing kits would encourage more people to use Surrey’s Sexual Health Services.

7.     Members suggested that the main criteria for judging the performance of the integrated Sexual Health and HIV Services were outlined within point 9 of the report as these were the main areas of concern identified through the SHNA. The Committee heard from the NHS England representative in attendance at the meeting who stated that all but a very small number of HIV patients had transferred over to CNWL or to another provider for their ongoing care. Significant efforts had been made to contact those individuals who had not yet transferred from their previous provider and it was anticipated that the majority of these people no longer lived in the UK. Members were further advised that an HIV transition clinic had been put in place to address those challenges which had been identified by patients. NHSE was responsible for commissioning HIV services across England which meant that commissioners were required to implement services in line with a national specification.

8.     The Committee highlighted the importance of hearing what was happening on the ground to understand how the integrated service is working for patients. The Strategic Director for Adult Social Care and Public Health indicated that quarterly performance reports submitted by CNWL as well as regular feedback meetings between commissioners and Trust enable SCC and NHSE to hold CNWL to account on how it is performing against the contract. Members were also advised that commissioners utilised feedback from Healthwatch, CCGs and local representatives in order to ensure robust challenge of the Trust’s performance. The Cabinet Member for Health indicated that she had been contacted by Local MPs regarding the reconfiguration of Sexual and HIV Services in Surrey. She highlighted that Surrey was the lowest funded local authority area per capita for Public Health in England which meant that it had been necessary to take a significant amount of money from the Sexual Health Services contract to balance SCC’s Public Health budget. The Cabinet Member recognised that there had been challenges in implementing the new contract but highlighted that there had been no rise in specific conditions or teenage pregnancies during the transitional period.

9.     Members stated that it was important to focus scrutiny on the future of the Service to ensure that CNWL built the capacity and capability to deliver against the terms of the contract. It was, however, highlighted that looking at the implementation of the contract would ensure that lessons were learned from the process that could be used to inform future commissioning. Information was sought from officers on the extent to which deficiencies with Surrey’s pre-existing sexual health and HIV service providers had caused some of the challenges which were being encountered by patients. The Strategic Director for Adult Social Care and Public Health confirmed that there had been confusion in some of the services offered at GUM clinics by previous providers which had led to some disruption for patients something that was being considered in detail by the Sexual Health Services Task Group. Members heard that collaborating on the integrated Sexual Health and HIV Service contract had been an important learning experience for both SCC and NHSE, this would continue as they worked together on managing the contract. The Service Director indicated that CNWL was limited in its ability to undertake due diligence with the previous providers and had only known in early March the number of staff that would be transferring over to the Trust.

10.  Further clarity was sought on the Patient Feedback Survey which had been undertaken by CNWL, the results of which had been published within the report. The Committee was advised that the results of the Survey were based on response from 309 patients which represented around 30% of patients who attended the Service over the course of an average week, the Service Director acknowledged that this was a not a significant sample. Members stated that it was hard for the Committee to draw any conclusions based on these results as it did not constitute a representative sample of patients using Sexual Health and/or HIV Services in Surrey.

11.  Concerns were also raised by Members about a lack of provision in the Spelthorne/ Runnymede area. Officers confirmed that Members’ concerns were legitimate given that certain aspects in this area had been lost during the transfer for a temporary period. Commissioners indicated that they would monitor the impact of not having specific provision in this area.

12.  The Deputy CEO of Healthwatch Surrey provided the Select Committee with an overview of some of the concerns that had been raised by patients. Members heard that representatives from Healthwatch Surrey had conducted a programme of enggement during which they had encountered a small number of patients who were having difficulties in accessing medication; these concerns had been communicated to CNWL. The accessibility of clinics operated by the Trust was also raised by the Deputy CEO of Healthwatch who highlighted that there were no online appointments available for clinics throughout February and March; services at Woking were not fully operationa which had meant that patients had had to travel to Guildford. Members also heard that there were significant physical access barriers at the Buryfields site including public transport and a long uphill walk.

13.  The Service Director recognised that there had been problems with the online booking system but informed the Committee that these had been addressed. Many of the challenges that the Service had experienced since it had been introduced had resulted from the TUPE requirements in transferring staff over to the Trust from the previous providers. Officers assured the Committee that the Service would be fully operational once the correct staffing structure had been introduced which it was anticipated would be by Christmas 2018. In terms of the accessibility of clinics, Members were informed that under the previous services, there were a large number of clinics but these had sporadic opening hours. Under the integrated Service, many patients would be required to travel further but in exchange they would receive a better service which meant that they were less likely to require a follow up appointment. It was further highlighted that CNWL had completed an access audit of all of its clinics and that the result of this audit would be shared with Healthwatch Surrey.

14.  The Deputy CEO of Healthwatch Surrey made the observation that the access audit had been committed, following a public question, at the last scrutiny session in November and the results were not available to the committee at today’s meeting.

15.  Members heard from the Director of Surrey Coalition of Disabled People who stated that the integrated Sexual Health and HIV Service was not well regarded by patients and made specific reference to publicity around the new Service indicating that schools were not being given information to pass onto pupils about where they can go to seek testing and treatment for sexual health conditions as well as contraceptive services such as the morning after pill. Further concerns were also raised about the role of the Blanche Heriot Unit Patients’ Working Group and the Committee was informed that issues raised through this forum were not being adequately addressed. The Strategic Director for Adults Social Care and Public Health stated that the data did not show any increase in teenage conception rates but that officers would continue to monitor this. The Committee also heard that rates of Sexually Transmitted Infections (STIs) were on the increase but that this mirrored national figures.

16.  The Committee heard from the Medical Director of Surrey and Sussex Local Medical Committee who informed Members that she had collated evidence from GPs in Surrey regarding the impact of the new Service. The response from GPs indicated that they had concerns about the new Service particularly around accessibility, Members heard that more patients were presenting at GP practices with STI symptoms placing an additional burden on doctors. The evidence also suggested that GPs found it difficult to refer patients to GUM Clinics due to a lack of information on the new Service. This had resulted in many patients being sent out of county for treatment. Members highlighted their concern that CNWL were not communicating appropriately with GPs around the new Service which was impacting on patient care. The Deputy Service Director stressed the importance of communicating with GPs and would work to ensure that all surgeries in Surrey knew where to find information about the new Service.

Recommendations:

The Adults and Health Select Committee:

1. recommends that commissioners seek feedback from patients who are going out of county for sexual health services;
2. recommends that the provider and commissioners communicate more effectively with GPs about the new service model;
3. requests that the commissioners collect data and patient feedback regarding the performance of the Service to be reported back to the Select Committee; and
4. agreed to review the Sexual Health and HIV Services in 12 months’ time.