Original ResearchRedesign and commissioning of sexual health services in England – a qualitative study
Introduction
Health services in England in recent years have undergone significant reforms following legislative changes set out in the Health and Social Care Act in 2013. These included a transfer of responsibilities for commissioning some public health services. Commissioning is the planning and purchasing of services to meet the needs of a population, which in England operates in a quasi-market.1 As part of the reforms, the commissioning of sexual and reproductive health (SRH) services are no longer solely the prerogative of the National Health Service (NHS). Local authorities in England are now responsible for a range of sexual health services that include treatment for sexually transmitted infections, contraception, sexual health promotion, as well as HIV prevention and testing services. However, HIV treatment services are now commissioned separately by NHS England, with abortion services being commissioned by General Practitioner (primary care)-led Clinical Commissioning groups (CCGs).2
This new responsibility to procure SRH services was challenging as many local authorities lacked prior experience of commissioning wholesale clinical services. The procurement process also provided a unique opportunity for sexual health services to be redesigned and developed. Numerous guidance documents were produced by the Department of Health, Public Health England and the Local Government Association to assist local authorities with their new commissioning responsibilities. These documents outlined various commissioning considerations including the benefits of developing local solutions, encouraging the adoption of a ‘whole systems approach’ via joint commissioning with different commissioning organizations, the role of clinical input, good governance, and the desirability for workforce development and training.3, 4, 5, 6, 7, 8, 9 The anticipated advantages of the reforms were redesigned services with a greater focus on prevention that were better enabled to address local needs including those of specific target groups. It was also envisaged that the reforms would lead to greater integration of SRH services. Prior to the reforms, contraception and sexual health (CASH) services and genitourinary medicine (GUM) services had traditionally been delivered as separate services in many areas, but there were now opportunities for them to be delivered as one service.10, 11
The reforms however were not universally welcomed and numerous concerns were raised.12 As noted earlier, the local authorities were less familiar with commissioning and managing clinical services. There were also funding anxieties as the reforms were implemented at a time of shrinking local authority budgets. While CASH and GUM services had been provided by separate providers in some areas, over time clinical care pathways and financial flows were established to make these arrangements work. However, the new procurement process has led to fracturing of these pathways and relationships. A good example is HIV where prevention is now the responsibility of the local authority, HIV treatment that of the CCG and HIV drug costs that of NHS England.12 The impact of the reforms on SRH workforce development, training, governance and accountability was also uncertain.10, 12, 13 This led to fears that the changes could result in worsening care, reduced access to services and marked variations in service provision between areas.14, 15
Health system and service redesign are complex and challenging. Whilst there is a growing body of literature around commissioning redesign,5, 16, 17, 18, 19, 20 the evidence base for this remains limited. The English experience is unique in view of the scale of the commissioning reforms introduced. Three years on, most of the English local authorities have gone through the reforms and recommissioned sexual health services. For many, this was a challenging endeavour. At the behest of local commissioners in the Yorkshire and the Humber region, this study was conducted to try to capture some of the experiences of procuring SRH services and lessons learnt in order to inform future commissioning and system redesign.
Section snippets
Methods
This study was carried out with local authorities in Yorkshire and the Humber. This region in the north of England has 15 upper tier local authorities and a population of 5.4 million.21 The localities include a mixture of rural and urban settings, with considerable variations in socio-economic as well as demographic characteristics, ranging from affluent suburban areas and rural villages to deprived inner city areas.
A qualitative study was carried out involving semi-structured interviews with
Results
Data were collected for this study from 13 commissioners from 11 interviews (see summary of themes and subthemes in Table 1). Six were public health consultants and seven were senior managers within public health teams.
Main finding of this study
This qualitative study documents the experience of commissioners procuring public health services in England following substantial health sector reforms. Uniquely, the reforms that have taken place have led to the transition of commissioning responsibilities for SRH services from a nationalized health system to local authorities, many of whom have had little prior experience of commissioning clinical services. Unsurprisingly, the process has been complicated and very challenging, requiring key
Acknowledgements
We are grateful to the Yorkshire and Humber Sexual Health Commissioners' Network for asking us to undertake this study on their behalf and to the interviewees who gave their time and for their willingness to be candid with us.
Ethical approval
Not required as this was a service review undertaken at the request of the commissioners' network.
Funding
None.
Competing interests
ACKL is an Associate Editor of the journal Public Health. ACKL played no part whatsoever in the editorial process or decision making in relation to this manuscript.
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