Decision Maker: Cabinet Procurement and Insourcing Committee

Outcome: For Determination

Is Key Decision?: Yes

Is Callable In?: Yes

Date of Decision: October 7, 2024

Purpose:

Content: RESOLVED to:   1.  Agree to the commissioning of a local core acute clinical sexual and reproductive health (SRH) service via Direct Contract Award C for a period of up to eight years and for the reciprocal cross charging for out of area access to continue. Payment for this service is primarily based on the activity delivered. The budget for the local SRH service contract will be a maximum of £28.992m (ex VAT).   2.  Agree the commissioning of Open Doors, the programme that offers holistic support to on-street and off-street sex workers including sexual health services and substance misuse support via Direct Contract Award C for a period of up to eight years at a maximum cost of £2.710m (ex VAT).   3.  Agree to City and Hackney continuing to participate in the online sexual health e-service (see paragraph 5.6) and be named party in the recommissioning of a new service in 2026 by the City of London Corporation as part of the London Sexual Health Programme. Hackney’s contribution over the anticipated contract period of 9 years will be £10.8m (ex VAT).   4.  Agree the recommissioning of primary care based clinical services from community pharmacies and GPs by Direct Award A for a period of up to eight years at a cost of up to £5.264m. For the GP services, this would be a single combined contract for the enhanced sexual health services and NHS Health Checks with the City & Hackney Integrated Primary Care CIC, the new name of the recently merged GP Confederation and Office of Primary Care Networks.   5.  Agree to access third party arrangements in order to meet the open access mandate for sexual health, via contracts agreed with out of area providers by local authorities using the London Integrated Sexual Health Tariff (ISHT), or via cross charging according to tariffs published by City and Hackney. The expected expenditure on out of area provision across the eight years is £13.840m.   Additional funding option:   6.   To enable rapid deployment of any additional (national government grant) funding provided to local authorities, we are seeking permission to include an option to increase the value of contracts, including NHS Health Checks, by further sums allocated to the Council, currently estimated to be approximately a further 25%, as part of the procurement options. Any such option to increase individual contract values up to £2m in value would be taken via the Hackney Procurement Board to allow suitable oversight of the option but also rapid deployment in the event that additional funding is provided. Any increase in contract value above £2m would necessitate a CPIC decision.     Reasons For Decision   Sexual health clinical services   1.  The sexual and reproductive health (SRH) need has been evidenced as per the needs assessment (updated version in progress here) and the very high levels of sexually transmitted infections diagnosed in City and Hackney every year, as well as an increase in new HIV diagnoses in 2022, in comparison with previous years. Differential outcomes in SRH are linked to age, sex, sexual orientation and ethnicity, as well as socio-economic circumstances that can cause or exacerbate health inequalities.   2.  The SRH strategy adopted by both the City and Hackney Health and Wellbeing Boards (HWB) and by Hackney Cabinet demonstrates the accountable commitment to this area of public health. An action plan has been developed to support the implementation of the strategic objectives. A HWB sub-committee representing senior leadership from across City & Hackney has been appointed to oversee the implementation process, promote greater system wide partnership working, and ensure continued action planning over the five-year life span of the strategy.   3.  A tiered approach is taken to sexual health services provision with lower complexity services provided in primary care and online (Community Pharmacy, GP practices, e-service) being tier 1 and tier 2, and more complex services being provided from tier 3 services (acute sexual health clinics). However, residents can choose via the open access mandate where to access sexual health services from any provider across England and without the requirement for a referral from primary care.   4.  The open access mandate will be met by commissioning local primary care enhanced services as well as a local core acute clinical service and making provision for residents to access both an online sexual health service, the e-service, and for out of area access at eligible clinics across London and England.   5.  Payment for accessing clinic based sexual health services is activity based by means of a local tariff for primary care and for acute services via the integrated sexual health tariff with cross charging to the resident’s local authority.   6.  The e-service is commissioned on behalf of London Authorities by the London Sexual Health Programme, hosted by the City of London, and a new service will be recommissioned in 2026. This service provides for the provision of home sampling of sexually transmitted infection (STIs), partner notification, some STI treatments and a limited range of contraception with the cost of services recharged on a tariff to the local authority of residence.   7.  A further expansion of the remit of the recommissioned e-service is expected to include the provision of PrEP to make it easier and more convenient for residents to start or continue with PrEP, a key HIV prevention tool. An interim 18 month pilot of digital or online PrEP is currently under consideration for interim commissioning by a number of local authorities including City and Hackney.   8.  In commissioning sexual health services, the local authority will support delivery against the 5 main sexual health Public Health Outcomes  Framework measures: ·  under 18 conceptions ·  chlamydia detection rate  ·  new STIs diagnosis (excluding chlamydia in the under 25s) ·  prescribing of long-acting reversible contraception (LARC) excluding injections (females aged 15 to 44) ·  people presenting with HIV at a late stage of infection   9.  Hackney and the City of London have very high levels of need for sexual health services as evidenced by high rates of STIs and unwanted pregnancies. This is due to a combination of our local demographics including a young population, larger proportion of global majority communities and a relatively large population of men who have sex with men, especially in the age group between 25-44 (11%) who have higher recorded sexual health needs, higher incidence of STIs and high uptake of services at sexual health clinics.   10.Hackney has a young population with 62% of residents under the age of 40 with the highest uptake of sexual health services at clinics in those aged 22 to 40. 11.Young people in Hackney bear the burden of chlamydia infection, with a proportionally high burden of disease among young black men of Caribbean heritage.   12.Many inequalities and disparities in sexual and reproductive health outcomes, as well as access to and uptake of services, are tied to age, sex, sexual orientation and ethnicity, with links to socio-economic deprivation.   13.Sexual and reproductive health, need and choices are part of a lifelong continuum which requires a life course approach.    14.Despite improved partnership working, services for sexual and especially reproductive health remain commissioned in a fragmented manner due to long standing national policy decisions. This necessitates an even greater focus on collaboration and partnership working to ensure clear and effective referral mechanisms and pathways.   15.Sex workers have specific sexual health needs with those street sex working having additional complexities and vulnerabilities from dependent alcohol and drug use, increased rates of domestic abuse, homelessness and violence.   16.Supporting clients through outreach and drop in to access drug and sexual health treatment services, harm minimisation, overdose prevention and exit street based sex working are all key outcomes from the service provided across City and Hackney.   17.A specialist service has enabled a trusted relationship to be established with this vulnerable group and both sexual health and substance misuse needs to be effectively addressed.   18.The local City and Hackney clinical sexual health services not only treat sexual ill health but also provide for sexual good health through encouraging preventative approaches e.g. provision of PrEP, encouraging condom use, vaccinations, partner notification and sit alongside the sexual ill health prevention services as detailed in key decision AHI S392.   19.There are five overarching objectives for service delivery:- ·  To prevent, and reduce late diagnosis of, HIV transmission ·  To prevent, and ensure timely treatment of, new sexually transmitted infections (STIs) ·  To improve access to choice of contraception and reduce unwanted pregnancies, promoting and increasing the use of the most effective and reliable forms of long acting ·  reversible contraception (LARC) ·  Help promote better health and wellbeing by ensuring linking with other services, such as drug and alcohol services and domestic violence services ·  Help address the wider social determinants of sexual ill health.   20.The overall outcomes for the clinical sexual health services are:-   ·  Increase uptake of long-acting reversible contraception, including for disadvantaged or under-served communities and decreasing the number of unwanted pregnancies ·  Increase the uptake of HIV testing, reduce late HIV diagnoses and preventing new infections ·  Ensure timely results and follow-up for all STIs and improve immunisation, to help to reduce the risk of onward infections ·  Offer and uptake of screening and brief interventions in line with Making Every Contact Count principles, with onward signposting or referral to other community services as needed ·  Ensure screening/identification and interventions for health and social risks such as domestic violence, child sexual exploitation, Female Genital Mutilation (FGM), and child and adult safeguarding, as part of local arrangements for pathways of care and support ·  Improve sexual health promotion, HIV prevention and uptake of sexual health interventions including LARC in key and vulnerable groups through targeted interventions and promotion, encouraging innovation ·  Monitor and improve the quality and experience of services for all users, including annual service user engagement plan   21.NHS Health Checks - The Local Authority is also legally mandated to make provision for the NHS Health Checks programme provided for eligible residents from GP practices and a new single contract to include both sexual health services and Health Checks is proposed.   22.Health Checks were launched in 2009 to reduce ill-health from cardiovascular disease (CVD), which was then the biggest killer of adults: it still causes 24% of deaths, second to cancers. People aged 40 to 74 with no known pre-existing CVD are eligible for an NHS Health Check every five years.   23.CVD can often largely be prevented by healthy behaviours and lifestyle, for example stopping smoking, reducing alcohol intake, maintaining a healthy diet and exercising regularly. However, in areas of deprivation a complex interplay of the wider determinants, impact of trauma, disadvantage and discrimination, including racism, often combine to increase levels of cardiovascular risk factors. The NHS Long Term Plan identified CVD as the single biggest area where the NHS can save lives over the next 10 years.    24.Millions of people are unaware that they are living with serious but treatable conditions such as atrial fibrillation, high blood pressure (hypertension) and high cholesterol. Spotting risk factors early reduces the chance of developing potentially life-threatening conditions including heart attacks, stroke and dementia.   25.The NHS Health Check programme aims to improve the health and wellbeing of adults (aged 40-74 years) through the promotion of early awareness, assessment, and management of the major risk factors for CVD – risk factors that are associated with premature death, disability and health inequalities in England.   26.The NHS Health Check estimates an individual’s risk of having a heart attack or stroke in the next 10 years and of developing type 2 diabetes. Underpinning this is an assessment of six major risk factors that drive early death, disability, and health inequality: alcohol intake, cholesterol levels, blood pressure, obesity, lack of physical activity and smoking. People aged 65 to 74 are also made aware of the signs of dementia. The NHS Health Check also seeks to reduce the likelihood of CVD-related illnesses by helping people to adopt healthier behaviours, referring to existing specialist services, or by prescribing medication such as statins.   27.The programme objectives include: ·  To promote and improve the early identification and management of the individual behavioural and physiological risk factors for vascular disease and the other conditions associated with those risk factors. ·  To support individuals to effectively manage and reduce behavioural risks and associated conditions through information, behavioural and evidence based clinical interventions. ·  To help reduce inequalities in the distribution and burden of behavioural risks, related conditions and multiple morbidities. ·  To promote and support appropriate operational research and evaluation to optimise programme delivery and impact, nationally and locally.   28.Priority outcomes for the local service include: ·  raised awareness of NHS Health Checks amongst the eligible population in City of London and Hackney ·  increased awareness in the local population of the risk factors for vascular disease and how to avoid or reduce them ·  appropriate communication of individual disease risk plus tailored advice offered to all those attending an NHS Health Check on appropriate lifestyle changes to reduce or manage this risk ·  placement on relevant at risk registers of all high risk clients, managed according to local care pathways ·  placement on relevant disease registers of all diagnosed clients, managed according to local care pathways.   29.In City and Hackney, NHS Health Checks are currently carried out in GP Practices, by Health Care Assistants, nurses and GPs. Residents are invited to attend a health check through their GP practice, via letter, telephone calls and/or text messages.   30.Over 43,000 NHS Health Checks have been carried out in the last five years. In 2023/24, 12,421 NHS HCs were delivered across City and Hackney, which was 18% above the annual target of 10,514.      Alternative Considered and rejected   Option 1 - End the services at the currently scheduled contract end dates and do not commission all or any of the clinical services ·  This option considers the implications of ceasing the delivery of all or some of the clinic services in City and Hackney ·  Local Authorities are legally mandated to provide for the testing and treatment of STIs, provision of a range of contraceptive options, partner notification with an open access mandate whereby residents can choose to access services out of area. ·  Whilst not commissioning the full range of services outlined may provide a saving in year one, costs in future years would significantly rise above any immediate savings as residents accessed more services at a tier 3 level out of area. ·  Commissioning an integrated local tiered sexual health service not only reduces cost of provision but also enables rapid access to services for local residents which is essential in reducing onward transmission and where some services such as emergency hormonal contraception need to be provided within a specific short timeline. ·  NHS Health Checks is a cornerstone of cardiovascular secondary prevention helping to detect hypertension, diabetes and provide both lifestyle and pharmacological treatments to reduce the risk of heart disease and strokes. ·  Health Checks have led to decreases in CVD risk, Body Mass Index, smoking prevalence, blood pressure and total cholesterol. Not commissioning this service would increase preventable death and disability. ·  Both sexual health services and NHS Health Checks are included as a legally mandated service for local authorities to commission. Not providing for these services would open up the authorities to legal challenge and breach the conditions of the ring fenced public health grant.   Option 2 - Re-procure the current clinical services via a competitive procurement process ·  The new procurement regulations for clinical services implement changes which place a greater emphasis on the need to collaborate, integrate and reduce the need for competitive procurement. ·  Opting for a procurement route other than via direct contract award would be contrary to the local and national strategic direction of increasing partnership working with the local NHS. ·  Social benefits, environmental priorities and best value will still be maintained during direct contract award and benchmarking of costs is a key part of the direct award using existing contracts and regional comparators as reference costs. ·  For the enhanced services (sexual health and health checks) primary care services from Community Pharmacies and GP practices there are no other providers who are able to deliver this service due to the nature of the commissioning arrangements of these national NHS services   Option 3 - Re-procure clinical services using Direct Contract Award A for Primary Care and Award C for Acute Sexual Health Services and Open Doors ·  This option considers re-procuring the clinical services through direct contract award ·  There are existing service providers from local NHS partners based in City Hackney including Primary Care and the Homerton to provide acute services ·  Direct contract award is in keeping with the new Provider Selection Regime (PSR), and allows for a procurement route which recognises existing services  performing well and that no substantial changes are being proposed that necessitate a different award route ·  However, the requirement for savings from the recommissioning of services either directly through a lower or non-inflationary increased cost of service, channel shift to lower tier services may make it difficult or impossible to agree a new contract with the service providers without increasing the price paid for services. The regulations provide some flexibility but any increase in the value of the contract due to inflationary pressures would need to comply with Regulation 13 of the PSR (Modification of contracts and framework agreements during their term). ·  If a contract award at the tariff prices or maximum contract value is not achievable through the direct award process then this would present a risk to service provision which may necessitate the need to undertake further market testing, review of costs of provision or identification of lower levels of activity but with higher cost per patient seen.   Option 4 – Insourcing ·  Hackney Local Authority does not have the infrastructure in place to fulfil the requirements of these clinical health services. ·  Many of the services to be commissioned are provided as additional or “enhanced services” to existing services such as Community Pharmacy or GP based services. ·  In terms of the GP Enhanced Sexual Health and the NHS Health Checks, these are delivered within the GP practices because it requires access to registered patient data. Insourcing will require significant system changes in order to be able to access patients records/data which may not be possible or are likely to take many years and significant discussion to achieve. The Council does not have the infrastructure in place or data sharing agreement to access the information necessary to provide an insourced service ·  This is a clinical and highly specialised service which requires formal clinical expertise and clinical supervision.  Neither LBH nor the City of London Corporation has the required professional staff nor structures to undertake this. ·  Insourcing would increase costs, delays, impact negatively on local partnership working and may not be achievable in terms of data sharing.   Option 3 is the preferred option.