North Yorkshire County Council

Executive

30 November 2021

North Yorkshire Integrated Sexual Health Service

Report of the Corporate Director – Health and Adult Services and Director of Public Health

1.0       Purpose of Report

1.1       To provide the Executive with an update on the Section 75 agreement between NYCC and York and Scarborough Teaching Hospitals NHS Foundation Trust (YSFT) following a 60-day consultation on the proposed service model changes to the Integrated Sexual Health Service.

1.2       To request that the Executive:

i.     Delegate the approval of the draft content of the Section 75 Partnership Agreement and associated schedules to the Corporate Director for Health and Adult Services in consultation with the Director of Public Health, the Assistant Chief Executive Legal and Democratic Services and the Executive Member for Public Health; and

ii.     Approve commencement of a 30-day consultation on the draft content of the Section 75 Partnership Agreement.

2.0       Background

2.2       Sexual and reproductive health is not just about preventing disease or infection. It also means promoting good sexual health in a wider context, including relationships, sexuality and sexual rights. Good sexual health is a vital aspect of overall health and wellbeing. However, poor sexual health outcomes fall disproportionately on certain groups. Sexual health spans the three domains of public health, health improvement, health protection, and healthcare public health.

2.3       Since 1 April 2013, Local Authorities have been mandated to ensure that comprehensive,

open access, confidential sexual health services are available to all people who are present

in their area (whether resident in that area or not). The requirement for Genito-Urinary

Medicine (GUM), Contraception and Sexual Health (CaSH) services to be provided on an

open access basis is stipulated in the Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013.

2.4       During 2013/14 the Public Health team invested significant time on a major redesign and

procurement of an integrated sexual health service for North Yorkshire, resulting in the contract being awarded to one provider for a service which was historically delivered through nine different contracts including inheritance of the military sexual health function.

2.5       York and Scarborough Teaching Hospitals NHS Foundation Trust is the provider of the integrated sexual health service in North Yorkshire (YorSexualHealth). The contract commenced 1 July 2015 with an expiry date of 31 March 2018. Within the existing contract, there was the option to extend for a further two years; this was utilised taking the expiry date to March 2020. Since then due to financial negotiations and subsequently COVID-19 further extensions, 12 months and 6+6 months approved via key decisions with end date of 31 March 2022.

2.6       £958,048 has been saved over 5 years from the existing contract. Due to COVID-19 in 2020/21, a significant underspend on the Primary Care and out of area budgets was achieved, with reductions in activity, and associated prescribing costs.

2.7       On September 3 2019 NYCC Executive approved proposals for the initiation of a Section 75 agreement covering up to ten years for delivery of an integrated sexual health service between NYCC and YSFT subject to a 30-day consultation.

2.8       On 26 November 2019 NYCC Executive received feedback on the outcome of the

            consultation and delegated the final decision (subject to YSFT Board approvals) to

Corporate Directors of Strategic Resources and Health and Adult Services, and the Director of Public Health in consultation with the Executive Members for those respective portfolios.

2.9       On 13 July 2021 NYCC Executive received a revised position on the progress of the Section 75 following the onset of the COVID-19 pandemic; this included finance, governance, timescales and proposed service changes. The Executive recommended to the Chief Executive Officer that he use his emergency-delegated powers to:

            i) approve the proposed budget for the Section 75 Agreement and delegate the final budget to the Corporate Director of Health and Adult Services in consultation with the Corporate Director of Strategic Resources; and

            ii) delegate the approval of the consultation on the proposed new service model to the Corporate Director for Health and Adult Services in consultation with the Director of Public Health and the Executive Member for Public Health.

3.0       Issues

3.1       NYCC and YSFT are intending to enter into an initial 4-year partnership agreement with an option to extend for a further 4 years, and 2 years (4+4+2). The future financial uncertainty beyond 4 years made it difficult to work beyond this period for both organisations. Therefore, the financial envelope has only been agreed for the initial term of 4 years.  The finances for the extension periods of 4 and 2 years will be subject to negotiation and agreement with YSFT, with a fall-back position that if no agreement can be reached and the parties still want to extend the agreement, the finances for the initial 4 years will apply.

3.5       In light of the budget reductions there were proposed service changes (outlined below) as part of a 60-day online public consultation and virtual workshops for partners (4 August – 4 October 2021).

3.6       The draft Section 75 Agreement and all associated schedules is with York and Scarborough Teaching Hospitals NHS Foundation Trust for comment, however the finances are agreed. One schedule of the S75 Agreement relates to the cross-border charging element of sexual health service. The proposed cross-border charging element is referenced within the main body of the Section 75 Agreement; however, it does sit in a separate schedule and is an attached signed agreement. The reason it sits as an attachment is that the cross charging is in place for North Yorkshire residents who access York clinics, whilst both NYCC and City of York Council (CYC) have the same Provider. This element therefore only remains in place as long as CYC continue to have YSFT as their Provider for sexual health services. The arrangement involves a block payment of £195,000 based on previous actual activity within York clinics. There is an element of risk share upon actual activity reconciliation undertaken at the end of a financial year.

3.7       The timescales for this piece of work remain a challenge for 1 April 2022, although progress does remain on track pending comments from YSFT on the draft Agreement.

4.0       Outline of Service Model

4.1       NYCC and YSFT developed an amended service model in light of budget reductions and COVID-19. YSFT considers the new model to be affordable within the reduced financial envelope. The proposed changes (below) were then subject to a 60-day public consultation.

4.2       Proposed service model summary:

· Sexual health promotion and information – a revised digital offer that puts choice and control at its core. A new offer that provides a convenient, efficient and cost effective method for e-sexual and reproductive health services. Further development of digital information, advice and signposting to self-care.

· Contraceptive services – an enabling approach with General Practice partners to support repeat contraception. The service will offer repeat contraception to those under 19 and to all ages after the issue of emergency contraception.

· STI services – a new tailored arrangement for online provision, offering a more targeted approach to convenient and accessible STI testing resulting in a more responsive and proactive approach to monitoring prevalence and responding with targeted testing treatment and partner notification.

· Training – customer focused, based on training needs of the local sexual health partners delivered via increased remote means e.g. webinars.

· Clinical and community outreach – a targeted and combined approach will be mobilised to best support the people with the greatest or most complex needs. This joined up approach will see clinical practitioners, community development workers and counselling therapists working together to provide practical support, an outcomes focused team supporting people to take control of their sexual and reproductive health.

· YSFT will make continued efficiencies regarding staffing over the 5 years, avoiding redundancies by adjusting skill mix through staff turnover and sourcing alternative accommodation both clinical and non-clinical to reduce high rents.

5.0       Performance Implications

5.1       Nationally, North Yorkshire ranks 26th / 149 Local Authorities for sexual and reproductive health outcomes. In a comparison to 16 nearest CIPFA neighbours NY ranks 2nd for sexual and reproductive health outcomes (Devon 1st with higher spend).

5.2       The provision of contraception is widely recognised as a highly cost-effective public health intervention. When considering total cost savings across the public sector (including both healthcare and non-healthcare cost savings), the Return On Investment (ROI) is £1.86 after one year (exceeding break-even) and £4.64 over 5 years. Over 10 years, the ROI is £9.00, or in other words, there is an £9.00 saving for every £1 invested in publicly provided contraception.

5.3       The existing provider is very experienced and has established a high quality, well-regarded integrated sexual health service across North Yorkshire, which is continually reviewed to explore ways of improving service delivery. The existing provider is performing to expectations and often above, delivering the Key Performance Indicators (KPIs) within the contract, and works closely with the Council to address any areas of concern that may arise.

5.4       A refreshed Service Specification and Performance and Outcomes Framework will remain in place as part of the Section 75 agreement, these documents will form the basis of the agreement.

6.0       Policy Implications

6.1       The integrated sexual health service supports the local population outcome which is that “all people in North Yorkshire experience good sexual health” as set out in the local strategic framework for sexual health.

7.0       Financial Implications

7.1       To address the decrease in the Council’s Public Health Grant allocation in September 2019 Executive approved a 2% reducing budget on the integrated sexual health service contract value, this equated to a saving of c £260,000 after five years.

7.2       Following a review of the Public Health Grant position, a revised annual reduction of £144,299 minimum efficiency saving will be applied across all the sexual health budgets. This includes an upfront year 1 reduction of c£120,000 from the YSFT budget and £25,169 from Primary Care.

7.3       The Partnership have agreed the annual budget for the Section 75 agreement between NYCC and York and Scarborough Foundation Trust over the next 4 years. The annual budget is £2,987,450, including cross charging, with an annual saving to NYCC of c. £120,000. In addition, any annual Public Health Grant uplift for NHS pay will not be passed on, and retained as further savings. With a 4-year fixed term agreement with two options to extend, this will allow both parties to review the financial position and service model 18 months before the initial term (or extension period) expires, with a 1-year notice period to extend.

7.4       The revised budget and savings plan has been approved by Health and Adult Services Leadership Team, and Management Board and via the delegated decision process. This was set in the context of the wider Public Health Grant appraisal with no adverse impact on achieving a balanced budget.

8.0       Legal Implications

8.1       The Local Authority is required as part of its public health statutory duties to ensure that comprehensive, open access, confidential sexual health services are available to people in

North Yorkshire (whether they live here or not). This is set out in Regulation 6 of the Local

Authorities (Public Health Functions and Entry to Premises by Local Healthwatch

Representatives) Regulations 2013.

8.2       Section 75 of the National Health Service Act 2006 and the NHS Bodies and Local

Authorities Partnership Arrangements Regulations 2000, S.I. 617 (“Regulations”) enable

NHS bodies to exercise prescribed local authority health-related functions in conjunction with their own NHS functions. The power to enter into section 75 agreements is conditional on the following:

i. The arrangements are likely to lead to an improvement in the way in which those functions are exercised; and;

ii. The partners have jointly consulted people likely to be affected by such arrangements.

8.3       Under the Public Contracts Regulations 2015 (PCRs) two contracting authorities can enter

into a collaboration agreement (co-operation) subject to meeting the tests of Regulation 12

(7) PCRs (known as Hamburg) without the need to undertake a procurement exercise.

9.0       Consultation Undertaken and Responses

9.1       A 30-day joint consultation between both NYCC and YSFT began on 7 October 2019 and   ended 6 November 2019. The NHS and Local Authorities Partnership Arrangements Regulations 2000 stipulate, “the partners may not enter into any partnership agreements [under Section 75 of the NHS Act 2006] unless they have consulted jointly such persons as appear to them to be affected by such arrangements”. The consultation set out the proposal to put in place a formal Partnership Agreement for the delivery of the Integrated Sexual Health Service and invited comments from both the public and interested parties.

9.2       The consultation and responses fed back to NYCC Executive on 26 November 2019 were overwhelmingly supportive of entering into a Section 75 partnership with 38 in agreement and 1 in disagreement.

9.3       The recent 60-day joint public consultation ran from 4 August – 4 October 2021 on the proposed changes to the service model as described above. The full consultation report is at appendix 1. 105 responses were received from the online consultation with a good split between public and professionals, across the age ranges and local areas. Two virtual consultation events for partners took place with low attendance, however received excellent feedback. We received overwhelming support for all of the proposed service changes.

9.4       Headline consultation results:

83% of respondents support additional online and virtual support within the sexual health service, to complement face-to-face service delivery. The intention of the enhanced digital/telephone offer is not to displace individuals away from face-to-face appointments when clinically necessary. The overall purpose of the virtual offer alongside face-to-face services is to facilitate a wider sexual health service reach across North Yorkshire. The triage process will ensure that people will be swiftly navigated to the right place this includes ensuring symptomatic individuals, or those requiring certain treatments, get access to face-to-face appointments in a timely manner.

87% of respondents support a personalised offer to STI testing based on individual’s level of risk and history.

The focus of this proposal is to carry out appropriate testing, rather than restricting access to testing. If there is no risk identified, or re-testing is not required, then there is often no reason to test.

The aim of the service is to be able to direct resources to the people and communities that require it most and tests will still be accessible for those that need it.  All public services have a duty to make sure that they remain cost effective and expenditure applied accordingly.

93% were in support of a coordinated approach between the sexual health counselling and HIV support services.

To reassure there will be no reduction in the provision of counselling services in the integrated sexual health service. The intention is to share skills across teams that will be able to enhance the service offer and meet the needs of a larger number of individuals requiring this element of service offer.

89% of respondents support a joint clinical and community approach with a focus on people with greater levels of risk or need across the county.

The service will continue to facilitate community/face to face and virtual sexual health care that will meet the needs of people with greater sexual health risks and needs. The service offer will be reviewed using a combination of service user/professional feedback and KPI monitoring. The clinical and community approach acknowledges the specific access needs and preferences of those groups and will offer the flexibility and responsiveness required to facilitate access and participation in both prevention and care.

9.5       In light of the support for the proposed changes from the 60-day consultation, a final 30-day consultation is due to commence in early December 2021 on the draft Section 75 framework content, including all associated schedules such as the service specification and performance framework. Following this 30-day period, the Partnership will review and make any final amends with the intention of Executive reviewing and approving the final Section 75 Agreement in early 2022.

10.0     Impact on Other Services/Organisations

10.1     The Council will work with the Provider to ensure that there is no significant negative impact on the health and wellbeing of the North Yorkshire population.

11.0     Equalities Implications

11.1     An Equalities Impact Assessment (EIA) on the integrated sexual health service is complete and attached at Appendix 2.

12.0     Recommendation(s)

12.1     The Executive is asked to note the contents of this report and to:

i.     Delegate the approval of the draft content of the Section 75 Partnership Agreement and associated schedules to the Corporate Director for Health and Adult Services in consultation with the Director of Public Health, the Assistant Chief Executive Legal and Democratic Services and the Executive Member for Public Health; and

ii.     Approve commencement of a 30-day consultation on the draft content of the Section 75 Partnership Agreement.

Richard Webb

Corporate Director – Health and Adult Services

County Hall

Northallerton

19 November 2021

Report Author – Emma Davis, Health Improvement Manager

Presenter of Report – Louise Wallace, Director of Public Health / Richard Webb, Corporate Director

Health and Adult Services.

Appendices:

Appendix 1 – Consultation Report

Appendix 2 – EIA