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HIV and AIDS Related Health Services Report by the Comptroller and Auditor General NATIONAL AUDIT SCE HIV and AIDS Related Health Services Ordered by the House of Commons to be printed 16 October 1991 London: HMSO X6.80 net 658 This report has been prepared under Section 6 of the National Audit Act, 1983 for presentation to the House of Commons in accordance with Section 9 of the Act. John Bourn Comptroller and Auditor General National Audit Office 15 0ct0ber1991 The Comptrollerand Auditor Generalis the head of the National Audit Office employing some 900 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies use their resources. HIV AND AIDS RELATED HEALTH SERVICES Contents Pages Summary and conclusions 1 Part 1: Introduction and background 7 Part 2: Planning and funding arrangements 11 Part 3: Treatment and care services 20 Part 4: Local prevention initiatives 25 Glossary of terms 28 Bibliography 29 Appendices 1. Summary of national AIDS public education campaigns 30 2. Summary of AIDS costing studies 32 3. The use of ring fenced funds 33 4. Summary of service rovision at main treatment centres in England and Scot Pand 34 HIV AND AIDS RELATED HEALTH SERVICES Summary and conclusions 1. The Acquired Immune Deficiency Syndrome [AIDS), first identified in the United Kingdom in 1981, is caused by infection with the Human Immunodeficiency Virus (HIV). The three main ways in which the infection is transmitted are through unprotected sexual intercourse, sharing needles and syringes with an infected person, or from infected mother to baby. Currently there is no vaccine against HIV nor a cure for AIDS. 2. The Government have set two broad policy aims in response to the rapid development of the HIV/AIDS epidemic: . the prevention of the spread of HIV infection: . the provision of diagnostic and treatment facilities, and counselling and support services for those infected or at risk. (Department of Health: AIDS, Cm 925 1968-89). In support of these aims, the Government allocated over E450 million over the period 1985-86 to 1990-91 towards the costs of HIV and AIDS related health services. By the end of 1990, 15,166 HIV seropositive people and 4,098 AIDS cases had been reported in the United Kingdom. Although it is very difficult to predict the likely spread of infection, HIV and AIDS related services are likely to continue to require a substantial commitment of National Health Service and other resources for the foreseeable future. There is, for example, evidence of rapid growth in the number of people infected wth HIV through heterosexual intercourse. 8. This report presents the results of an examination by the National Audit Office of HIV and AIDS related health services administered in England by the Department of Health and health authorities, and in Scotland by the Scottish Office Home and Health Department and health boards. The study examined: . the arrangements for the planning, funding and provision of health services in response to the HIV epidemic; . the measures established locally aimed at preventing the spread of HIV and AIDS. Planning 4. Rapid developments in the treatment and care of HIV/AIDS patients have taken place against a background of considerable uncertainty concerning the nature and spread of the disease. The National Audit Office’s main findings and conclusions were: Findings (a] under-reporting of the numbers of HIV seropositive people and AIDS cases has occurred in some health authorities in England. For 1 HIV AND AIDS RELATED HEALTH SERVICES example, two health districts have identified significant discrepancies between the number of HIV seropositive people known to the authority, and those recorded by the national surveillance system (paragraphs 2.9 and 2.10); (b) health districts in England were sometimes unable to plan more than twelve months ahead, mainly due to uncertainties over the future numbers of patients and changing patterns of care. In Scotland, health boards also had problems in assessing the scale of service and resource needs, but used epidemiological predictions and estimates of service needs to plan AIDS patient facilities (paragraph 2.16); (c) in England the voluntary sector, local authorities and primary care services have not always been invited to contribute to the planning of local health services. The responsibilities of the various statutory bodies have at times been unclear (paragraphs 2.17 and 2.18). Conclusions 5. More accurate predictions of the future prevalence of the disease would help the departments to resource, and health authorities and boards to plan, future services for HIV and AIDS patients. Difficulties in obtaining accurate data about the current spread of the disease reflect a number of factors including the voluntary nature of testing and reporting. Measures are being taken both nationally and locally to improve reporting levels and available information. For example, the programme of anonymised testing will help to predict the number of people infected with HIV. 6. The National Audit Office conclude that, on planning, health authorities in England should: . take further steps to reduce the amount of under-reporting of HIV infection, for example by ensuring that health authority and centrally held data are consistent; . develop and strengthen the joint planning and funding of collaborative projects between health authorities, local authorities and the voluntary sector in order to reduce overlap andhelp complement the workof the variousagencies; and both health authorities and health boards should: . improve local knowledge about the population at risk so that the purchase and provision of services can be planned according to assessed need. Funding arrangements 7. The departments allocated additional funds to help prevent the spread of HIV infection and to provide treatment for those affected. In England, these funds were ring fenced. The main findings and conclusions were: Findings (a] the Department of Health and health authorities have difficulties in obtaining sufficient costing and activity data to assess and target AIDS funds (paragraph 2.25); 2 HIV AND AIDS RELATED HEALTH SERVICES (b) the Department of Health have used the reported number of live AIDS cases to determine the proportion of resources allocated to each region for treatment and care of both HIV and AIDS patients. However, the ratio of people with HIV to AIDS varies across the country and is changing over time. The Department acknowledged that their system for allocating resources may be crude and that health authorities also need to develop further an objective method of allocating funds (paragraphs 2.26 and 2.27); (c) regions in England were given a sudden large increase in AIDS allocations in 1989-90 which virtually doubled funds over the previous year. This led to an underspend of fl5 million out of the f17.1 million allocated. Some health authorities used the underspends on other activities. At the time of the National Audit Office fieldwork there had been only limited scrutiny by both the Department of Health and regions but the Department have recently strengthened their monitoring arrangements (paragraphs 2.28, 2.32 and Appendix 3); (d) in Scotland there were significant underspends of both specific and general AIDS allocations in 1989-90. The Scottish Office Home and Health Department recognised that allocations to health boards have not fully reflected service needs and have improved their allocation and monitoring arrangements (paragraphs 2.35 to 2.41); (e) the funding mechanisms in England for the voluntary sector are unclear. Funding may come from a variety of statutory sources, each with their own criteria for approval, and allocated at different times during the financial year (paragraph 2.45). Conclusions 8. The health departments do not have sufficient cost information to enable them to target their resources in the most effective way. And it is doubtful whether, in England, the present basis for allocating resources remains valid in the light of changes in the pattern of treatment and care and the shifting balance between those with AIDS and those with HIV. The Scottish Office Home and Health Department have revised their allocation method and the Department of Health are now collaborating with health authorities to improve the method of allocation. 9. The National Audit Office conclude that on funding: . health authorities/boards need to improve their cost and activity data. This would assist the departments and health authorities/boards in identifying resource requirements and in evaluating service options; . the Department of Health should further develop their system for allocating AIDS funds to health authorities. Resources need to be targeted more closely to the areas of greatest need: . the departments, health authorities and boards need to ensure that AIDS funds are used for the purposes intended; 3 l health authorities should review their systems for funding voluntary sector services. Application procedures should be simplified and more clearly defined. Provision of treatment and care services 10. In England the treatment and care of people with HIV and AIDS has been concentrated in a number of key hospitals in London and different models of care have evolved at these centres. In Scotland specialist AIDS units have been developed in Edinburgh, Glasgow
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