Who Decides What HIV Services You Will Get

What is commissioning?

When talking about health and social care services, commissioning describes the process of: 

• identifying the needs of a population
• planning how to meet these needs through appropriate services
• deciding who will provide the services, and
• paying for the services.

The recent changes to the NHS are changes to commissioning - in particular, who is now responsible for commissioning services.  This means that there are new processes for making decisions and new bodies and forums where these decisions are made.

Who decides which services will be available in my area?

A national body called NHS England commissions services for health conditions which are too rare and specialised to be managed by local CCGs. This includes HIV treatment and care. NHS England also commissions GP, dentist and pharmacist services (called primary care).

Local authorities (councils) commission social care services in their area – these are support services to help people live independent and fulfilling lives (see section on Social Support). 

Local authorities also commission public health services for their communities.  Public health is about making sure communities are supported to stay healthy and avoid illness. This can include things like vaccinations, health promotion campaigns (e.g. on stopping smoking or healthy eating) and sexual health services (including clinics and prevention campaigns). So your local authority must provide sexual health (GUM) clinics (except for HIV treatment) and HIV prevention services.¹ 

What is the Health and Wellbeing Board?

Each local authority has a Health and Wellbeing Board  who can be contacted . This is a forum where the decision makers – local authorities, CCGs and local representatives of NHS England – come together to make plans for your local services.

Each year the Health and Wellbeing Board sets outs the priorities for services in the local area through two key documents:  the Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS).¹  (For more information see What are JSNAs and JHWSs and why do they matter?)

The Health and Wellbeing Board also signs off all commissioning plans made by the Local Authority and CCGs, having checked that these reflect the priorities outlined in the JHWS.

The Health and Wellbeing Board’s job is to make sure that these plans for health and social care work well together to meet the needs of local communities. Health and Wellbeing Boards should also make the commissioning process clear and responsive to local communities.² 
 

What does NHS England do for my local area?

NHS England publishes a national HIV Service Specification. This tells your HIV clinic what services it must provide.

Even though NHS England is a national organisation, it operates through 4 regions (North of England, Midlands and East, London and South of England.  There are also 10 commissioning hubs,with the job of commissioning HIV treatment and care (as well as care for other specialised conditions). So they will commission the HIV care not just in their own local area but also in some of the neighbouring areas.¹ 

When commissioning HIV treatment and care, HIV England  takes advice from a Clinical Reference Group (CRG) on HIV. This group is mostly made up of HIV doctors, who represent each of the NHS England regions. There are also patient and carer representatives.  You can see the membership of the HIV CRG on their website.

What is the Overview and Scrutiny Committee?

Every local authority with a Health and Wellbeing Board must also have an Overview and Scrutiny Committee.  This is a committee of local councillors who have the job of scrutinising how NHS services and social care are commissioned and provided.

You can find out more about your local Overview and Scrutiny Committee on your local council website.  There will be information on their meetings, work programme and how you can get your voice heard.  You can suggest topics that the Committee should look at. 

The Overview and Scrutiny Committee can require NHS and social care commissioners to attend its meeting and explain their decisions on a particular issue.  After looking at an issue, the Committee will make recommendations.  These recommendations are not mandatory but they must be considered and responded to by the decision-makers responsible.

The Overview and Scrutiny Committee has a lot of influence so they are worth approaching if you want to see improvements in your health and social care services.

What are JSNAs and JHWSs and why do they matter?

All decisions that commissioners make - for health, public health and social care – must take into account the Joint Strategic Needs Assessment (JSNA) and Joint Health and Wellbeing Strategy (JHWS) prepared by the local Health and Wellbeing Board (HWB).  This should mean that services reflect the needs and priorities of the local community, which were identified through research and consultation with local people.¹ 

The JSNA is a process of looking at the characteristics of the local community and what health, social care and public health needs exist in the area. The JHWS sets out which of these needs are to be prioritised when funding services.  

What are the Outcomes Frameworks?

Decision makers must report to their communities how well they are achieving a range of specific ‘outcomes’ for the health of their population. These are outlined in a set of Outcomes Frameworks which cover NHS, public health and social care services. The set of outcomes and the way of measuring progress against them is the same across all areas, so it is possible to compare how different local areas are doing.

For example, one of the indicators of how well a local area is doing at health protection is the proportion of people diagnosed with HIV who are diagnosed ‘late’ (after they should have started treatment). Your local area should be trying to reduce the proportion of people diagnosed late.¹ 

There are other, broader outcomes which health services are supposed to achieve that are relevant to people living with HIV. These are called the ‘domains’ of the NHS Outcomes Framework and sum up how good healthcare is defined by the NHS:

• preventing people from dying prematurely
• enhancing quality of life for people with long term conditions
• helping people to recover from episodes of ill health or following injury
• ensuring people have a positive experience of care
• treating and caring for people in a safe environment; and protecting them from avoidable harm.² 

Appendix 2 of the BHIVA Standards of Care³ links back to these domains of the NHS Outcomes Framework, showing how specific aspects of good quality HIV treatment and care can contribute to achieving these outcomes. So you can refer to the NHS Outcomes Framework when arguing for the high quality HIV care set out in the BHIVA Standards.

[1] Public Health Outcomes Framework - http://www.phoutcomes.info/ 

[2] NHS Outcomes Framework  https://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/ 

[3] BHIVA Standards of Care - Appendix 2 http://www.bhiva.org/ClinicalGuidelines.aspx

What is the duty to reduce health inequalities?

NHS England (who commission HIV treatment as well as primary care services) and Clinical Commissioning Groups (who commission secondary care services) have a duty to reduce health inequalities.¹ 

‘Health inequalities’ is a way of describing the way that some groups and communities have poorer health than others.  The duty to reduce these inequalities requires decision-makers to address both barriers to accessing services and differences in how certain groups benefit from these services.

Local authorities should also be working to reduce health inequalities in their community as part of their public health duties.  This could include thinking about the needs of groups most affected by HIV – such as gay men and African-born women and men - with prevention, testing, social support and other relevant services.

_{[1] Health and Social Care Act 2012 http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted}