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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.