Paul Ward, Deputy
Chief Executive of the Terrence Higgins Trust (THT),
does not mince his words when it comes to his predictions for HIV.
“I think services for
people with HIV are going to go through the biggest single change since the
start of the epidemic,” he says. “There is a good chance we will see
significant reductions in voluntary sector provision and its almost total
disappearance in some areas.”
In terms of medical
care, he says, we are likely to see a big shift from HIV care in hospitals to
HIV care in local health facilities, though not necessarily by GPs.
He acknowledges that
there have been predictions that uncomplicated HIV treatment will become part
of local, non-hospital-based health care for years, and it hasn’t really
happened. “This time round, though, I think it’s different. There really is a
lot less money to go around, and there will be a different set of commissioners
in the driving seat.”
The consortia of GP
practices that would commission services would, for a relatively specialist
condition like HIV, need to be large and look after a whole region such as
Yorkshire or the North West.
But, he warns,
“Experience shows that, once you get GPs in charge, there will be a lot more
emphasis on value for money.”
This doesn’t mean the
HIV sector would have no say in how services were configured. As HTU Readers’ Panel member Robert James
points out, GPs may decide that HIV is such a “messy and complicated” area,
they will farm the whole process of commissioning out to a health consultancy –
which could be a private firm but could equally be an organisation like THT.
Dr Mike Youle, an HIV
specialist who has criticised substandard HIV care in the past, doesn’t
necessarily think this is a bad thing. “The NHS is slow to use the
possibilities of e-clinics, home delivery of drugs and all the things that free
up time and allow concentration on real clinical services.”
And David Castelnovo,
a specialist HIV nurse in Brighton, agrees.
“We as NHS trusts have not been very good at managing our budgets…it’s only
recently that we adopted home delivery, which saves £1000 per patient per year
in VAT alone.”
Paul Ward predicts that
the stable majority of people on HIV – the people who have no need to change treatment
– may be increasingly managed by specialist nurses like David who are attached
to one or more local clinics.
When it comes to
social care, Paul predicts a shake-out of services “bigger than that in the
late 1990s when many of the old drop-in centres closed.
“Local authorities are
facing cuts of 35% to social services. They will have to cut provision to the
bone, to only cater for the people to whom they have a clear statutory
obligation: children, the elderly, and a few adults such as those with severe
learning or other disabilities or mental illness. THT sees many, many people
with high social care needs who, nonetheless, are not statutorily eligible for social care.”
He regrets the ending
of the ringfence for the AIDS Support Grant but thinks that the scale of the
funding cuts would have overshadowed any difference made by keeping it: “Even
before it went, in the last few years it was getting hard to show that all of
the money was getting to people with HIV.”
In response to the
changes, THT is planning to increase the services it provides via the internet
and over the phone, and predicts a lot of other organisations will have to do
the same. “Organisations may not have paid staff to provide in-person services
or, if they do, won’t necessarily have a building to do it from.”
LifePlus, THT’s new
website (see below) is an example of this new kind of provision. A
Department of Health kitemark is now available for health and social care information,
and providers can apply for accreditation under it to certify the information
they produce is reliable and up to date.
A separate NHS consultation
on a proposed information strategy, covering everything from websites to
patient records and health audits, is currently underway.
But not everyone uses
the internet. African people in particular have reported that they prefer
one-to-one, video or interactive services and that, if they do use the
internet, they often do so in places where confidentiality is a problem. Paul Ward
points out that despite this stated preference, a study from Homerton Hospital
presented at the Vienna International AIDS Conference this year7
found that African women were avid readers of HIV information websites.
When it comes to
prevention and public health, the situation is different in that the
government, in shifting responsibility for public health from PCTs back to
local authorities, has allocated new
ringfenced money for its provision.
However Paul Ward is
quite sure that prevention programmes and interventions will be more tightly
controlled than before. This is because the other, central plank of the new NHS
strategy is to rely on outcome,
rather than process, measures. This means scrapping a lot of the Labour targets
such as waiting-list times. In the case of HIV prevention, anything that
doesn’t get local HIV and STI infection rates down will have a hard time
justifying being funded.
Ward thinks that there
is room for unfairness and discrimination in this new slimmed-down world,
citing especially the new wave of people ageing with HIV (see The prescription for old age) who may have specific needs
such as gay-friendly and HIV-aware care homes. He also believes that many
people will suffer from the changes to welfare benefits.
“We need to recognise that
there will be a big impact on people with HIV, and we will need to fight for
their rights and help increase employment amongst people with HIV.”