The scale of the problem in London
London has the highest prevalence of sexually transmitted infections (STIs) and HIV in the country and faces significant sexual health challenges:
- nearly half of all people living with HIV in England live in London
- men who have sex with men (MSM) make up 2% of London’s adult population yet 24% of newly diagnosed STIs
- 1 in 8 MSM in London have HIV, with 20% undiagnosed
- London has the highest STI rate in England, 65% higher than any other region
- under-25 year olds experience particularly high STI rates – 37% of new infections in Londoners were in those aged between 15 and 24 years
- we have seen increases in 2014 of 40% in syphilis diagnoses and 23% in gonorrhoea diagnoses
- there were new 44,810 diagnoses of chlamydia in London in 2014.
The high and rising demand for sexual health services takes up a significant percentage of public health budgets. It is projected that, without action, almost 100 per cent (or more) of those budgets in London will be spent on sexual health in under five years. This has underpinned the need for action and fostered the collaborative responses between London councils described here.
How are sexual health services delivered?
Local authorities have had responsibility for commissioning most sexual health services since April 2013, accounting for over a third of all public health spending in 2013/14 and demand continues to increase.
The sexual health services landscape is complex, with responsibility for providing services being divided between local authorities, clinical commissioning groups (CCGs) and NHS England. Local authorities are responsible for commissioning comprehensive and integrated sexual health services, including contraception, STI testing and treatment and specialist services (including HIV prevention). Delivery of services involves a broad range of providers, including NHS acute and community providers, GPs, pharmacies and the voluntary, community and independent sector.
Local authorities must, by law, provide open-access sexual health services for everyone in their area, to control infection, prevent outbreaks and reduce unwanted pregnancies. It means that people can access services anywhere, and providers then invoice the local authority where that person lives. As a result, councils are paying bills for contracts they played little or no part in negotiating. In London, this complex system is exacerbated by having such a mobile and young population, and because public health funding does not take account London’s high level of needs.
There are more than 30 GUM clinics in London. Residents frequently use clinics outside their own borough. Currently, London boroughs spend more than £100m each year on GUM services. The continuing increase in London’s population, its demographic profile and the trend of increasing STI rates, means that expenditure increases every year.
The London Sexual Health Transformation Programme
The London Sexual Health Services Transformation Programme is a partnership of 29 London boroughs with the aim of drawing together a new collaborative commissioning model for sexual health services. From April 2017, when the Programme is due to be implemented, patients will be able to access services through the internet rather than having to attend a clinic. The programme aims to:
- deliver a new collaborative commissioning model across the participating councils for sexual health services in London, in particular open access GUM services
- improve the patient experience and sexual health outcomes
- provide successful cost effective delivery of excellent services across the capital
- reduce the incidence of STIs, HIV and teenage pregnancies.
Survey of how people use sexual health services in London
The Programme ran a survey of how people use sexual health services in London, including GPs, GUM, STI and contraceptive services. The survey closed at the end of March.
There are a number of key reasons why joint commissioning of services can help improve outcomes:
- There are significant variations in access and activity across London boroughs, with high numbers of residents from across London using services in central London
- Due to London’s complex pattern of open access services, there are important advantages for London boroughs to transform and commission services together
- It is important to ensure there is consistent strong clinical governance, safeguarding and quality assurance arrangements across London when commissioning open access services.
Recent London Councils analysis of projected STI diagnoses across England show that London is the only region to see a projected growth between 2014 and 2024. It is estimated that London boroughs will see a 5 per cent rise in demand for sexual health services over the next 10 years.
All of this has financial implications. For example, failure to prevent the 1,088 UK-acquired infections in MSM diagnosed in London in 2012 will cost the health service an estimated £348 million in future direct health-care costs. It is widely accepted that this situation needs to change.
Vision of how services will work in future
From April 2017, when the Project is due to be implemented, patients will access services through the internet. They will be provided with information about sexual health, on line triage, signposting to the most appropriate service for their needs and the option of ordering self-testing kits. GUM clinics will be open longer hours and will be linked with a network of integrated local one stop shops. They will also work closely with primary care. Having good transport links will be crucial to decide where the clinics should be located. There will be a single database with full protection of security and confidentiality, to enable tracking patients' treatment and enabling the project to focus on those who need help most.
Clinics will offer patients the opportunity to triage and self-sample on site and routine STI test results will be available electronically to patients within 72 hours. Patients who are diagnosed with an STI will be offered an appointment within 24 hours or will be fast tracked if they present to a walk in service.