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Greater Manchester Joint Commissioning Board
Date: 21 January 2020
Subject: Establishing an Integrated Greater Manchester Sexual and Reproductive
Health System
Report of: Sarah Price, Executive Lead, Population Health and Commissioning, GM
Health and Social Care Partnership
PURPOSE OF REPORT:
This report seeks the agreement to a decision-making process to enable the progression of
a programme to develop an Integrated Greater Manchester Sexual and Reproductive Health
System.
KEY ISSUES TO BE DISCUSSED:
Agreement of the appropriate governance mechanism for making the required
decisions in relation to this programme of work.
RECOMMENDATIONS:
The Greater Manchester Joint Commissioning Board is asked to:
Confirm the role of JCB as the system decision-taker in relation to the progression of
a programme to develop an Integrated Greater Manchester Sexual and Reproductive
Health System.
Agree the steps required to enable these decisions to take place.
Agree to receive final business proposals in April 2020.
CONTACT OFFICERS:
David Boulger, Head of Population Health Transformation, GMHSC Partnership
SYSTEM ENGAGEMENT
Please complete the information below to outline the discussion with sectoral governance groups prior to submitting to the GM Joint Commissioning Board. If it is not appropriate / deemed necessary for a discussion with a particular group please state why.
PRIMARY CARE ADVISORY GROUP (PCAG) Has the paper been discussed by PCAG?: Yes Date of meeting: 5/12/19 Key points to be fed into JCB:
Support in principle for the approach and the proposals
Keen to see more detail around Primary Care proposals, including demand implications and finance considerations.
PROVIDER FEDERATION BOARD (PFB) Has the paper been discussed by PFB? No If no please outline the reason: This work remains at a formative stage and was instead taken to GM Provider Directors of Strategy in December 2019. Engagement with all required groups will take place during the next phase of this planned programme of work. Date of meeting: 20/12/19 Key points to be fed into JCB:
Recognition of the issues that we are seeking to resolve
Support for the proposed model
Support for the proposed 2 phases transformation programme WIDER LEADERSHIP TEAM (WLT) Has the paper been discussed by WLT? No If no please outline the reason: This work is at its formative stage and engagement to date has taken place with subject matter experts and has primarily been progressed through Greater Manchester Directors of Public Health, Greater Manchester Population Health Programme Board, the Greater Manchester Sexual Health Strategic Board and the Greater Manchester Sexual Health Commissioner Network. Engagement with all other required groups will take place during February and March 2020 subject to a decision-making pathway being agreed by JCB. Key points to be fed into JCB: Not applicable. STRATEGIC PARTNERSHIP EXECUTIVE BOARD (PEB) Has the paper been discussed by PEB? No If no please outline the reason: This work is at its formative stage and engagement to date has taken place with subject matter experts, and has been progressed through Greater Manchester Directors of Public Health, Greater Manchester Population Health Programme Board, the Greater Manchester Sexual Health Strategic Board and the Greater Manchester Sexual Health Commissioner Network. Engagement with all required groups will take place during the next phase of this planned programme of work.
Key points to be fed into JCB: Not applicable. GM CCG DIRECTORS OF COMMISSIONING (DOCS) Has the paper been discussed by DOCS? Yes (Paper sent to meeting) Date of meeting: 10/12/19 Key points to be fed into JCB: No feedback received. GM CCG CHIEF FINANCE OFFERS (CFOS) Has the paper been discussed by CFOS?: Yes (Paper sent to meeting) Date of meeting: 10/12/19 Key points to be fed into JCB: No feedback received.
GM LA HEADS OF COMMISSIONING (HOCS) Has the paper been discussed by HOCS? No If no please outline the reason: This work is at its formative stage and engagement to date has taken place with subject matter experts, and has been progressed through Greater Manchester Directors of Public Health, Greater Manchester Population Health Programme Board, the Greater Manchester Sexual Health Strategic Board and the Greater Manchester Sexual Health Commissioner Network. Engagement with all required groups will take place during the next phase of this planned programme of work. Key points to be fed into JCB: Whilst this work has not been to GM LA Heads of Commissioning, the responsibility for commissioning Sexual Health actually sits with Directors of Public Health, who have led this work, and it has regularly been to GM LA Sexual Health Commissioners Network and the GM Sexual Health Strategic Partnership. GM DIRECTORS OF PUBLIC HEALTH (GMDsPH) Has the paper been discussed by GMDsPH? Yes Date of meeting: 6/12/19 Key points to be fed into JCB:
GMDsPH continue to support this programme and the ambition to move towards the overarching integrated model.
GMDsPH support the emergent transformation proposals and the phased approach.
GMDsPH are keen to ensure that this transformation is driven by localities with support and co-ordination from GM.
GMDsPH have taken the responsibility to ensure that locality colleagues are informed and engaged.
1.0 PURPOSE
1.1. This report seeks the agreement to a decision-making process to enable the
progression of a programme to develop a Greater Manchester Sexual and
Reproductive Health System that is more integrated, comprehensive and
consistent.
1.2. Sections 2 to 6 restate the context, provenance and emergent proposals.
1.3. The emphasis for this JCB discussion pertains to section 7 which relates to
governance and decision-making.
2.0 CONTEXT
2.1. The ambition to establish a more integrated GM Sexual and Reproductive Health
system is longstanding in nature and has previously been included within the GM
Population Health Plan, GM Public Health System Reform proposals and the GM
Commissioning Review.
2.2. GM localities, under the leadership of the GM Directors of Public Health and the GM
Sexual Health Network, have strived over recent years to work collaboratively to
improve outcomes and to reduce variance across the city-region. In doing so they
have made significant improvements to the system that have enabled expenditure
to be reduced without compromising the quality of the service provided or the
outcomes for GM residents.
2.3. This has provided a solid foundation upon which to develop a more integrated,
comprehensive and consistent Sexual and Reproductive Health System for Greater
Manchester, which meets the needs of local citizens and responds to the Sexual
and Reproductive Health challenges that exist in contemporary society.
2.4. In 2018 GM Directors of Public Health commissioned an external review of the
current system which aimed to:
• Review the current approach to Sexual & Reproductive Health and HIV services
in Greater Manchester;
• Identify existing and future system challenges, strengths, risks and
opportunities;
• Identify areas of good or emerging practice from within Greater Manchester,
across the UK, or internationally in relation to Sexual and Reproductive Health
systems and whole system approaches to transformation;
• Explore these opportunities to further realise the vision set out for Greater
Manchester, with particular attention to the opportunities through whole system
integration, primary care, emerging digital offers, and estate rationalisation;
• Develop a set of draft and final proposals in the form of a report and associated
presentation and present this to key system stakeholders for feedback;
• Make recommendations on the contracting or procurement routes to best deliver
these proposals.
3.0 SCOPE
3.1. The Independent Review, and the emergent model for Greater Manchester,
incorporated the entirety of the all age Sexual and Reproductive Health system,
including:
Prevention
Primary Care – Sexual Health and Contraception
Secondary Care – Sexual Health and Contraception
HIV Prevention and Treatment
Drug Costs
Termination Services
4.0 THE CURRENT SYSTEM – KEY FACTS
4.1. The specialist Sexual and Reproductive Health system in Greater Manchester
experiences significant levels of demand, with over 300,000 face to face
appointments taking place each year within specialist clinics.
4.2. In Greater Manchester there are considerable service pressures and challenges to
ensuring individuals are receiving appropriate support in a timely manner. The
reasons for this is multi-faceted, but include an increase in the incidence rate of
some Sexual Transmitted Infections, including syphilis and gonorrhaea, and the
provision of PrEP in relation to HIV.
4.3. Local Authority expenditure on Sexual and Reproductive Health services is
currently c.£26million per year in GM, but only £1.1million is specifically invested
each year in GM on dedicated prevention services through a contract with the
Passionate About Sexual Health (PaSH) VCSE consortia.
4.4. Only £700,000 specfically invested each year in GM on dedicated services for
Children and Young People, with most locality services now being commissioned to
provide an all age approach, including providing contraception and sexual health
support to Children and Young People, and identifying and responding to
safeguarding issues, including childhood sexual exploitation. Over recent years,
there has been a 43% decline in attendances at sexual and reproductive health
services for 13-15 yr olds, and a 31% decline in attendances at sexual health and
reproductive services for 16-17 yr olds.
4.5. NHS England expenditure on HIV Care and Treatment is currently c.£54million per
year in GM, whilst GM continues to experience high rates of late diagnosis.
4.6. Use of Contraceptive Services in GM has fallen by 22% over 4 years, including a
13% fall in the Long Acting Reversible Contrception (LARC) rate (double the rate of
decline in England), whilst Emergency Hormonal Contraception (EHC) use is 12%
higher than England. There is evidence of limited specialist contraception provision
within General Practice and high levels of variability across the City-Region. There
is a very limited pharmacy-based contraception offer in Greater Manchester largely
focussed on EHC.
4.7. At the same time the abortion rate (15-44) in GM has increased by 11% with
significantly higher rates than England for total abortion rate, under 25s abortion
rate and repeat abortions.
5.0 INDEPENDENT REVIEW – KEY FINDINGS
5.1. The Independent Review was structured around a SWOT framework and the key
findings are incorporated in Appendix 1 of this report.
5.2. In summary, the review found that whilst there are some considerable strengths
within the GM system, there were significant risks which could jeopardise the future
effectiveness, sustainability and safety of the system. However, there were also
significant opportunities identified in relation to self care, digital, HIV treatment and
neighbourhood based models for sexual wellbeing.
5.3. There is a current consensus within the system that the status quo is not an option
and that action is required to develop a system which responds to the identified
risks, maximises the existing strengths and harnesses the oportunities.
6.0 AN INTEGRATED MODEL FOR GREATER MANCHESTER
6.1. Discussions following on from the independent review led to the identification of a
series of opportunities and the development of an emergent overarching model for
a future Integrated Sexual and Reproductive Health system for Greater Manchester,
as set out below:
6.2. Over time, this model would realise:
The emergence of a truly integrated system for SRH (including HIV) in Greater
Manchester;
A shift in demand, value and resource from specialist care towards wellbeing
and care in neighbourhoods, person and community-centred approaches and
digital channels;
The strengthening of the ‘bedrock’ to ensure increased consistency and reduce
variance across Greater Manchester;
Greater alignment to new and emerging GM and locality system architecture
including the GM joint commissioning arrangements, locality joint
commissioning arrangements, locality care organisations, and the development
of Primary Care Networks.
6.3. Realising this opportunity will require extensive transformation, building upon the
positive work undertaken to date, and driven by localities with co-ordination and
support provided by colleagues from across GM.
6.4. The emergent model was first shared with GM Directors of Public Health on 11/1/19
and GM Population Health Programme Board on 29/1/19 and was endorsed with a
view to progressing from concept to detailed design. The emergent model was also
presented to the GM Sexual Health Commisioners Network on 17/1/19 and the GM
Sexual Health Strategic Board on 23/1/19 and was well received at both, with a real
desire expressed to move forward towards detailed design.
6.5. The emergent model was then presented to GM Joint Commissioning Board on
19/2/19 where it was agreed to undertake some more detailed design in relation to
establishing the pathway to developing the whole integrated model, and assessing
the desirability and feasiblity of the proposals. This design work has taken place
throughout 2019 and it is anticipated that it will be completed by March 2020.
6.6. The detailed design process has led to the emergence of a two phase approach,
with 4 business cases nearing completion within Phase 1, these being:
A Digital Sexual and Reproductive Health Offer for GM
Transforming HIV Prevention, Treatment and Care
Enhancing the role of Primary Care (General Practice)
Enhancing the role of Primary Care (Pharmacy)
6.7. Draft summaries of these proposals are included as Appendix 2.
6.8. Subject to a decision to implement these proposals being taken in Q1 2020/21, it is
anticipated that these programmes could be fully implemented by 31/12/2021. This
is due to the complexity of the proposed work programmes and the potential
changes to contractual arrangements and payment mechanisms that would need to
be developed to enable Phase 2.
6.9. Phase 2 of this programme would then focus upon the transformation of specialist
care, building upon the solid community-based support platform developed under
Phase 1. The design work relating to Phase 2 would commence in Q4 of 2020/21
with implentation planned from 1/4/2022.
6.10. A summary of the phased approach is included as Appendix 3.
6.11. These proposals have been developed in partnership with the GM Sexual Health
Network, GM Directors of Public Health, and with key colleagues within General
Practice and Pharmacy.
6.12. In addition, the emergent proposals have been shared with GM Primary Care
Advisory Group, GM Provider Directors of Strategy, GM Directors of Commissioning
and GM Chief Finance Officers.
6.13. Going forward, a series of Engagement Workshops have been planned to engage
other key stakeholders with an interest in Sexual and Reproductive Health.
7.0 GOVERNANCE
7.1. Governance and decision-making in relation to these proposals is complex as the
commissioning responsibilities sit across a number of partners, namely Local
Government, locality Clinical Commissioning Groups and NHS England. A
summary of these responsibilies is included as Appendix 4.
7.2. As a consequence, the existing contract and payment arrangements are highly
complex and shared across organistations and structures.
7.3. The decision to accept and progress the final proposals would need to be taken by
a governance structure with the authority to represent all of these parties.
7.4. It is felt that GM Joint Commissioning Board is the only decision-making
environment that could potentially perform this role, and this view was shared by the
GM Directors of Public health at their meeting on 6th December 2019.
7.5. As such, JCB members are asked to confirm if they are in agreement as to whether
JCB is the most appropriate governance environment for decisions to be taken to
enable the progression of a programme to develop a more integrated Greater
Manchester Sexual and Reproductive Health System, and to identify any additional
governance arrangements that would be required to enable these decisions to take
place.
8.0 TIMELINE
8.1. It is anticipated that final business proposals will be completed and socialised by
March 2020 and that this will include detailed design proposals, full costings and a
full cost benefit analysis.
8.2. Subject to a decision being taken as per the recommendations of this report, it is
planned that these final business proposals are brought to GM Joint Commissioning
Board in April 2020.
9.0 RECOMMENDATIONS
9.1. The Greater Manchester Joint Commissioning Board is asked to:
Confirm the role of JCB as the system decision-taker in relation to the
progression of a programme to develop an Integrated Greater Manchester
Sexual and Reproductive Health System.
Agree the steps required to enable these decisions to take place.
Agree to receive final business proposals in April 2020.
APPENDIX 1 – KEY REVIEW FINDINGS
Strengths of the current system:
A track record of transformation which has released significant savings (c.15%);
Agreed out of area / cross charging arrangements across Greater Manchester;
GM Common Standards for Sexual and Reproductive Health;
GM centralised booking system for termination services;
VCSE-led Passionate About Sexual Health (PASH) consortia delivering a single
GM prevention contract;
Consistency of commissioning approaches across most GM areas, and evidence of
some cluster commissioning arrangements;
Devolution of HIV treatment from NHS England to GM;
GM investment in dedicated programme to end new cases of HIV in a generation.
Weaknesses / Areas for Improvement within the current system:
Absence of a single, agreed GM Sexual and Reproductive Health Strategy;
Limited evidence of self care / self management / person and community centred
approaches;
Limited and variable Primary Care provision;
Limited digital / eHealthcare ‘offer’;
Model is very medicalised;
HIV treatment and care expenditure (Rightcare outlier);
Demand Management and System Flow;
Disinvestment over time in prevention and dedicated children / young people
services.
Threats to the current system:
Workforce capacity, capability and succession planning
Likely future reductions in investment
Likely future increases in demand
Uncertain future provider market
Sustainability of the current model
APPENDIX 2 – OVERVIEW OF EMERGING PROPOSALS
APPENDIX 3 – PHASED APPROACH
APPENDIX 4 – SRH / HIV COMMISSIONING RESPONSIBILITIES
