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 and Dundee. The main findings and conclusions were:
Findings (a) large inflows of HIV and AIDS patients are putting pressure on the established National Health Service centres in London (paragraph 3.5); (b) some general practitioners have been reluctant to play a full part in caring for people with HIV infection, particularly infected drug users. But initiatives are in hand to increase the involvement of general practitioners in the management of HIV/AIDS patients and there has been some improvement in general practitioner services within the main centres @aragraph 3.11); (c) the three main districts treating people with AIDS or HIV infection in London purchase essential hospice care from two voluntary groups, the Mildmay Mission and London Lighthouse (paragraph 3.14); (d) inpatient care has been provided on both dedicated AIDS wards and general acute wards; the length of inpatient stay has reflected the different needs of patients and local models of treatment and care. Most health authorities had or were developing programmes for evaluation of HIV and AIDS services. However, only a few authorities had evaluated inpatient services @aragraph 3.22); (e) in general, health authorities and boards visited stated that they needed more guidance on the format and content of the AIDS (Control] Act reports and would welcome more feedback from the departments. The Department of Health and the Scottish Office Home and Health Department issued new guidance in April and July 1991, respectively [paragraph 3.25); (f) there is considerable uncertainty and concern in health authorities, boards and the voluntary sector over how the National Health Service reforms will affect the future funding and provision of HIV and AIDS services. The departments are addressing this (paragraphs 3.26 to 3.29).
Conclusions 11. There is likely to be continued pressure on hospitals within London, given the open access to HIV and AIDS services. However, health authorities are trying to develop services outside the current centres of excellence. If community care is to be developed further, and continuity of care achieved, general practitioners’ involvement in the treatment of HIV and AIDS patients need to be increased.
12. The AIDS (Control) Act reports serve a useful function in indicating the spread of the infection, development of services and the
4 HIV AND AIDS RELATED HEALTH SERVICES
resources employed, but, although in common format, financial and other data sometimes lack consistency. This may therefore create difficulties for managers who wish to draw comparisons with services provided in different areas. 13. The National Audit Office conclude that on the provision of services health authorities and boards should: . assess the need to develop locally based treatment and care services to relieve pressure on the established centres; . continue to develop services which reflect patient preferences and help relieve pressure on inpatient facilities. This may be achieved by, for example, making available hospice and respite facilities, where appropriate, and encouraging greater general practitioner involvement; . plan to meet the range of needs created by the increasing numbers of heterosexuals, drug users and children with the virus; . evaluate services to compare alternative methods of delivery and quality of care. The results would enable health authorities to identify successful models of care and assist the further development of services. and health departments should: . improve the consistency of manpower, activity and financial information in AIDS (Control) Act reports to facilitate management review; . clarify arrangements for funding and contracting under the National Health Service reforms. Prevention initiatives 14. The health departments stress that preventing the spread of HIV infection is of crucial importance and that local health education and preventive initiatives are an essential part of their strategy. The main findings and conclusions were: Findings (a) expenditure per head of population on local prevention services varied significantly within district health authorities and health boards. Generally the higher prevalence areas spent more on prevention per person (paragraph 4.7); (b) successful local prevention initiatives have been introduced within health authorities and boards; for example schemes which allow drug users to exchange used needle and syringes for sterile ones are an integral part of many local prevention programmes (Table 5 and paragraph 4.10); (c) national campaigns were sometimes finalised at short notice which made it difficult for health authorities to support the campaigns. The Department of Health are seeking to remedy this (paragraphs 4.12 and 4.13); (d) health authorities experienced difficulties in evaluating the effectiveness of local prevention initiatives. The Health Education Authority have produced guidance to assist evaluation (paragraph 4.15).
0 5 HI” AND AIDS RELATED HEALTH SERVICES
Conclusions 15. Local prevention initiatives reinforce the need to change behaviour which creates a risk of HIV infection. The National Audit Office conclude that on prevention health departments, authorities and boards should: . improve their knowledge of their local population at risk and thus help ensure that prevention resources and initiatives are directed at those groups; . evaluate prevention initiatives and disseminate good practice on successful measures for example, schemes which allow drug users to exchange used needles and syringes for sterile ones using, where appropriate, the guidance already available: . ensure national and local campaigns are complementary. Closer collaboration between health authorities and the Health Education Authority, and between health boards and the Health Education Board for Scotland, should assist local development of prevention services,
General conclusions 16. The National Audit Office conclude that the health departments and the National Health Service have responded well to the emerging demands and uncertainties of the HIV and AIDS epidemic, and have developed innovative approaches to deal with the disease. They now need to review more rigorously the planning and funding arrangements for these services, and to evaluate outcomes. Only in this way can they be assured that full value for money is being achieved and that the Service can respond to future demands.
6 Part 1: Introduction and background
Background infected person, or from infected mother to baby. The risk of infection through transfusion of blood 1.1 The Acquired Immune Deficiency Syndrome and blood products has been virtually eliminated (AIDS) was first diagnosed in the United Kingdom through new blood screening and heat treatment in 1981 and is caused by the Human procedures. There is currently no vaccine against Immunodeficiency Virus (HIV]. This virus weakens HIV nor a cure for AIDS. the body’s immune system; once infected with HIV, people may experience a series of illnesses of 1.3 In the European Community the cumulative increasing severity. About half of the people number of AIDS cases reported in member states to infected with HIV are likely to develop AIDS within 28 February 1991 ranged from about 41 to 235 per 10 years of infection. million population (Figure 1). In the United Kingdom the cumulative number of positive HIV 1.2 The three main ways in which HIV is reports increased from 2,843 in 1985 to 15,166 in transmitted are through unprotected sexual 1990 although, as testing is voluntary, these figures intercourse, sharing needles and syringes with an are likely to be less than the actual number of
Figure 1
Reported AIDS cases per million population: European Community comparison
Greece
Ireland
Portugal
Germany
United Kingdom
Belgium
Luxembourg
Netherlands Italy
Dmmack
Spain
Prance 235 / I II SO 100 150 200 250 Rate per million population
Source: World Health Organisation.
7 HIV AND AIDS RELATED HEALTH SERVICES
Figure 2
HIV reports and AIDS cases in the United Kingdom from 1985 to 1990
Numberand reports Qf cases 20,000
Cumulative for previous year 10.000
0 1985 1986 1987 1988 1989 1990 Year Source: Data published by the Communicable Diseases Surveillance Centre.
infected people. Over the same period, reported Department of Health to provide a focus AIDS cases rose from 265 to 4,098 (Figure 2); and of within Government for work on HIV these 2,256 people had died. The incidence of the infection and AIDS; disease is not evenly spread: North West Thames l set two broad policy aims: and North East Thames Regional Health Authorities have reported over 40 per cent and almost 17 per - the prevention of the spread of HIV cent respectively of the cumulative total of AIDS infection; and cases in the United Kingdom (Figure 3). - the provision of diagnostic and treatment facilities, and counselling 1.4 People with AIDS are mainly young adults, a and support servicesfor those infected group which otherwise make little demands on or at risk (Department of Health: AIDS health services. Research commissioned by the Cm 925 1988-89); Department of Health found that the annual cost of caring for a person with AIDS was around E20,OOO l allocated total additional funding of +2399 at 1989-90 prices. Expenditure on health services million for HIV and AIDS services in for HIV and AIDS patients is expected to rise England (E360 million), Scotland (f34 significantly as the numbers infected increase. But million) and Wales (f5 million), over the predictions about the future incidence of the period 1985-86 to 1990-91; disease are subject to considerable uncertainty . provided f51 million for national because of behavioural changes and the prevention campaigns. development of treatments to combat the disease. In addition to these measures, the AIDS (Control) The Government’s response to HIV and Act 1987 requires each district health authority in ‘AIDS England and Wales, and each health board in Scotland, to publish annually information on the 1.5 In response to the epidemic, the Government: numbers of, and services provided for, HIV and l established in 1985 an AIDS Unit in the AIDS patients.
8 Figure 3
AIDS cases diagnosed and reported within Scotland, Wales, Northern Ireland and regional health authorities in England, up to 31 December 1990
Key: cumulative AIDS casesreported to the Communicable DiseasesSurveillance Centre and the Communicable Diseases(Scotland) Unit by the 31 December1990
0 o-99
seeNote (I) zi?dg5 m-
.1621
Source: Data published by the Communicable Disease Surveillance Centre. Note (1): Almost 90% of the cases in Scotland were reported in Lothian, Tayside and Greater Glasgow Health Boards. HIV AND AIDS RELATED HEALTH SERVICES
1.6 Health and local authorities and the voluntary arrangements were in place to meet the challenge sector provide treatment, care and social services of the disease. The study examined: for people with HIV infection and AIDS. Service . the arrangements for the planning, funding provision began in response to an emerging need and provision of health services in response identified by key London hospitals and by a number to the HIV epidemic: of newly formed voluntary groups. These have . the measures established locally aimed at remained at the forefront of providing care and preventing the spread of HIV and AIDS. support, but many other health and local authorities, and voluntary groups are now providing services. 1.10 The National Audit Office examination involved enquiries at the Department of Health and the Scottish Office Home and Health Department, 1.7 National UK-wide public education campaigns and other authorities: to inform the general population about HIV and North West Thames Regional Health Authority AIDS began in 1986. These are continuing and are Parkside District Health Authority now organised by the Health Education Authority Riverside District Health Authority on behalf of the health departments. At a local North East Thames Regional Health Authority level; district health authorities, local authorities Bloomsbury District Health Authority (now and voluntary organisations have introduced Bloomsbury & Islington) campaigns both to reinforce national prevention work and encourage behavioural change within Lothian Health Board target groups at greatest risk. The Health Education Greater Glasgow Health Board Board for Scotland also have responsibility in More limited enquiries were made at Oxford, North Scotland for the development of complementary Western and Trent Regions, and Tayside Health HIV/AIDS health education initiatives in Board. The National Audit Office also invited association with the relevant statutory and comments from two local authorities (City of voluntary bodies. Westminster, Lothian Regional Council), voluntary bodies (including Mildmay Mission, Terrence Higgins Trust, London Lighthouse, Scottish AIDS Select Committee Reports Monitor), and adademics. The National Audit Office fieldwork was undertaken over the period June 1.8 The Select Committee on Social Services have 1990 to December 1990. undertaken two enquiries into AIDS in the United Kingdom (HC 182 1986-87 and HC 202 1988-89). They recommended that: 1.11 In Scotland there is a high incidence of drug related HIV infection. Lothian Health Board alone . plans should be made for a variety of has 30 per cent of the United Kingdom’s known different types of care, including care in total of persons infected with HIV through injecting the community: drug use. The study did not include Wales where . service providers should monitor and the reported number of people with HIV and AIDS evaluate their work; is significantly less. l the funding of voluntary organisations should be on a longer-term basis; 1.12 The report does not address national . education campaigns among ethnic prevention strategies. The major public education minorities and other minority groups campaign in 1988 was considered in my report should be developed and sustained. “Publicity Services for Government Departments” [HC 46 of 1989-90 Session). A summary of the The Government’s reply [Cm 925, November 1989) national campaigns is at Appendix 1. endorsed the broad thrust of the Committee’s recommendations. 1.13 The Government has offered a f42 million Scope of the National Audit Office settlement to 1,200 haemophiliacs infected with examination HIV. This is in addition to an earlier settlement of f34 million paid to the McFarlane Trust to 1.9 Against this background, the National Audit distribute to those affected. The issue of Office set out to examine the response to the HIV compensation for infected haemophiliacs is outside and AIDS epidemic, in particular whether the scope of this study.
10 HIV AND AIDS RELATED HEALTH SERVICES
Part 2: Planning and funding arrangements
2.1 Rapid service developments for HIV/AIDS liaises with the Division of the Scottish Office Home patients have taken place against a backdrop of and Health Department which has similar considerable uncertainty concerning the nature and responsibilities. spread of the disease. In England and Scotland, the uneven distribution of the epidemic has prompted 2.4 Since 1986, the Department of Health have the evolution of a few major treatment and care issued guidance to health and local authorities centres. Lessons learned from these centres and highlighting the need to give particular attention to: experiences abroad have informed the departments’ local prevention initiatives; strategies and their planning of services. development of services for drug users; 2.2 Against this background the National Audit improvement of genito urinary medicine Office examined the arrangements made by the services; health departments and the National Health Service for planning health services and for targeting specific treatment and care services for rasourcas in response to the HIV/AIDS epidemic. people with HIV disease. Planning To achieve these aims, the Department of Health have set out detailed service objectives for health authorities, originally to be achieved by March Government strategy for countering HIV infection and AIDS 1991; guidance in April 1991 extended this to March 1992. 2.3 The Government have developed a five-part strategy to counter the impact of HIV infection and 2.5 In Scotland, the Tayler Working Party was set AIDS (Table 1). Oversight of this strategy and its up in 1986 to advise on the most appropriate and implementation are the responsibility of the health cost-effective method of organising services for departments. In the Department of Health an AIDS people with HIV and AIDS, and to quantify the staff Unit provides a focus within Government for work and resource costs. In 1987, the Scottish Office on HIV infection and AIDS, including international Home and Health Department asked health boards liaison. The Unit has a multi-disciplinary team and to take account of the Tayler recommendations Table 1
Government Strategy on HIV infection and AIDS
Prevention: To stem the spread of HIV infection through public awareness campaigns, community based prevention initiatives and improved infection control procedures. Monitoring surveillance and research: To improve understanding of the epidemiology of HIV infection, how it is transmitted, the natural history of the disease, and how HIV related illness can be prevented and treated. Treatment, care and support: To provide appropriate diagnostic, treatment, care and support services for those affected by HIV. Social, legal and ethical issues: Through a range of measures to foster a climate of understanding and compassion, to discourage discrimination, and to safeguard confidentiality, within the wider context of public health requirements. International cooperation: To foster and encourage the full and continuing exchange of information between countries, and to encourage countries not to adopt coercive and discriminatory measures.
Source: Department of Health Response to the Seventh Report of the Social Services Committee (Session 1988-89): AIDS.
11 HIV AND AIDS RELATEDHEALTH SERVICES
Figure 4
Incidence of AIDS in England and Wales: 1990 Day Report projection compared with the 1988 Cox Report projection
Annual number 5,000 - Day Report of AIDS cases upper projection observed and .I /I ,/ I projected 4,000 - COX Report ,’ /I ./ I ,/ / / 3,000 - / Day Report ,A’ planning projection 2,000 - /' .,./,A2 Day Report lsooo- / ------lowerprojection
I I I I I I I I I I 1984 85 86 87 88 89 90 91 92 93 Y&T Source: Day Report. Note: The numbers above represent the new diagnoses in each of the years shown. These differ from the figures in paragraph 2.7 which quote the cumulative number of live AIDS cases expected at year-end.
when planning their services for HIV infection and 2,350 deaths in 1992 in England and Wales. The AIDS. The Department funded the three specialist Day report (1990) reduced these predictions units for people with HIV and AIDS recommended significantly: 3,820 people with AIDS and 1,190 by Tayler in Edinburgh, Glasgow and Dundee. The deaths in 1992; corresponding figures for 1993, the Chief Medical Officer for Scotland set up a working latest available, were 4,980 and 1,540. In Scotland, group in 1990 to assess the resources needed to the Tayler report estimated that by the end of 1969 manage patients in the early stages of HIV infection. there would be 159 live AIDS cases: in the event The group is expected to report in autumn 1991. there were 68 known cases. In 1990 the McClelland report predicted that 620 people would have AIDS Forecasting demand for HIV/AIDS services by the end of 1992, and that there would be 190 deaths in 1993. 2.6 There are great uncertainties in predicting the likely spread of HIV in the United Kingdom. This is 2.8 National predictions of the incidence and due to incomplete knowledge of the biology of the spread of the disease in the Day and McClelland virus and HIV/AIDS related disease, the difficulties reports were based upon available up-to-date in obtaining information on the incidence of HIV information on caseloads and trends. They took into infection, patterns of behaviour in risk groups and account past experience of the epidemic, estimated the rate of spread, especially within the prevalence of HIV and reported numbers of HIV heterosexual population. seropositive persons and AIDS cases. They also allowed for 20 per cent under-reporting of HIV 2.7 Two reports commissioned by the Department seropositive people and AIDS cases. of Health predicted the number of people who would develop and die from AIDS (Figure 4). In 2.9 AIDS diagnoses are reported voluntarily and in 1968 the Cox report forecast there would be 5,250 confidence by clinicians to the Communicable people alive with AIDS at the end of 1992, and Disease Surveillance Centre run by the Public
12 HIVANDAIDSRELATEDHEALTHSERVICES
Health Laboratory Service. In Scotland a similar natal clinics in other parts of the country only one system is operated by the Communicable Diseases in 16,000 was HIV seropositive. (Scotland) Unit. Information on all HIV antibody positive tests is voluntarily reported directly by Health authority and board planning testing laboratories to the national surveillance 2.13 The Department of Health required all centres. In England, the Centre believe that more regions to prepare by March 1991 (now March 1992) than 60 per cent of diagnosed AIDS cases are a plan for the provision of HIV/AIDS related notified-which compares well with notification services. The Scottish Office Home and Health systems for other diseases, soma of which carry a Department were involved directly in planning the statutory obligation to report. The Department of level and distribution of services. Health told the National Audit Office that the Centre are making strenuous efforts to improve the standard of reporting. 2.14 Regions visited by the National Audit Office had prepared or were in the process of preparing a regional strategy or planning guidelines, but 2.10 In July 1988 the Department of Health asked progress varied. each health authority to review their systems for the monitoring and surveillance of HIV infection. In North West Thames Region established a North East Thames Region, Haringey District regional planning group in 1965 and have estimated the under-reporting of HIV positive tests provided planning guidelines to their was as much as 50 per cent. The Region intend to districts indicating how services should issue guidelines to districts on how to improve their develop; for example, the circumstances in monitoring. A validation exercise in Riverside which districts should provide dedicated District in 1990 highlighted discrepancies between inpatient and outpatient facilities. They the number of seropositive people known to the have also undertaken a number of region- District and those recorded by the Communicable wide initiatives, for example, on Disease Surveillance Centre. The study detected a prevention. total of 622 unreported HIV seropositive people (33 North Western Region published their per cent of the total) from two centres within the “Regional Framework for HIV and AIDS” in district. April 1990 emphasising the need for collaboration by all sectors. Each district 2.11 Given the wide range and complexity of has agreed to implement the framework services used by those with AIDS, health districts which has identified responsibilities for a consider difficulties in reporting AIDS cases to be range of services, for example, genito inevitable. Bloomsbury Distrct were concerned that urinary facilities. these problems might be exacerbated as general Trent Region aimed to complete their plan practitioners and general acute clinicians, not by April 1991. The plan will identify the necessarily linked into reporting mechanisms, respective roles of the Region and districts. become increasingly involved in the diagnosis of The Region expect that decisions on service AIDS cases. All districts and boards visited by the development will be guided by the plan. National Audit Office had recognised the need to establish effective local monitoring arrangements and the importance of prompt reporting. In 1990 the 2.15 All districts visited by the National Audit Chief Medical Officer at the Department of Health Office had prepared either a strategy or policy wrote to all doctors reminding them of the need to statement backed up by an annual plan. The main notify all new AIDS cases. London districts had established an AIDS advisory group or similar committee. In a number of 2.12 In January 1990 the Government approved the authorities a specific AIDS Co-ordinator post had introduction of a programme of anonym&d HIV been established to ensure consistent policies were surveys to help provide data about the general applied. prevalence of HIV acmss the country. This testing includes people attending some genito urinary 2.16 Districts were sometimes unable to identify medicine clinics, drug users, ante-natal attenders service and hence resource needs beyond a twelve and babies. The first results of the programme in 27 month period although the lead time for providing ante-natal clinics were announced in May 1991. inpatient facilities could be two to three years. They showed that the overall prevalence of HIV Short term planning was due to a number of factors infection in women attending ante-natal clinics in including uncertainties war the number of HIV inner London districts is now one in 500; in ante- positive people, changing patterns of treatment and
13 care, and patient flow. In Scotland, health boards employed on HIV and AIDS related services, also had problems in assessing the scale of service including 27 medical staff and 91 nursing staff. In and resource needs. However, Lothian Health Board 1988, the Department of Health asked all health used epidemiological predictions to plan inpatient authorities to determine, originally by March 1991 facilities. (now March 1992), the extra manpower required to meet the treatment and care needs of people with 2.17 The National Audit Office found that other AIDS; as at 31 March 1991 none of the health bodies, particularly the voluntary sector, local authorities had done this. However, no serious authorities and primary care services, had not difficulties were reported in recruiting new staff. always been able to contribute to the planning The health boards in Scotland did not have detailed process. North East Thames Region stated that manpower plans for HIV/AIDS related services at effective joint planning was the exception rather the time of the National Audit Office examination. than the rule. However, examples of good practice noted were: 2.21 The epidemic has also created demand for training in a number of key areas. The Department l OXAIDS, a voluntary body working in of Health required all health authorities to develop Oxfordshire, produced a guide to liaison an appropriate training strategy by March 1991 (now between the statutory and voluntary sector March 1992). Of the health authorities visited by [Oxford Regional Health Authority): the National Audit Office, all had introduced a . a community care team had close links number of initiatives such as awareness training on with voluntary groups (Bloomsbury District HIV infection and AIDS, and specific training for Health Authority). nurses and clinicians. Training plans were in various stages of development. Two of the 2.16 The Department of Health’s Social Services authorities and boards visited had undertaken a Inspectorate reported in 1990 that difficulties with review of training needs and North West Thames joint planning were common throughout England Region had published a strategy aimed at and this had led to confusion war the respective complementing efforts undertaken by districts responsibilities of health and local authorities, and within their Region and had funded a number of hindered the development of collaborative projects initiatives. For example, the Region have organised and effective joint planning of services. The Report general practitioner and nurse training in Riverside stated that Local Authority Social Services District. Departments were rarely involved in discussions with health authorities about how allocations were Funding in England used or given the opportunity to consider how community services might be jointly developed. General 2.22 In England, the Department of Health 2.19 In Scotland, health board and regional council introduced earmarked funding for AIDS and HIV boundaries are co-terminous, therefore, joint services in 1987-88. Since 1989-90, the Department planning and service co-ordination were easier to of Health have, exceptionally, ring fenced all AIDS achieve. All three boards visited were involved allocations. Guidance from the Department states with local authorities and voluntary bodies in that all monies must be spent in the pursuit of the strategic planning. For example, in 1988, Government’s broad policy aims, that is on Strathclyde Regional Council and its four health activities designed to prevent the spread of HIV boards, which includes Greater Glasgow, produced infection or to provide treatment, counselling and a strategy to guide the development of services in support for those infected or at risk. By ring fencing the Region. Each health board had a nursing and a these monies, the Department sought to give HIV medical AIDS Co-ordinator; the latter had primary and AIDS services priority where the demands responsibility for co-ordination of services and upon treatment centres were greatest and to ensure monitoring the spread of the infection and were that highly expensive treatments could be provided consultants in public health medicine. without detriment to other services. They also sought to ensure that all regions undertook Manpower planning and training initiatives to prevent the spread of HIV, not just the areas of highest incidence. 2.20 The increased demand for HIV/AIDS services has led to the recruitment of additional staff, Targeting resources at regional level particularly in the major treatment centres. For example, North East Thames Region estimate that 2.23 In 1989-90 the Department of Health in 1989-90 there were the equivalent of 309 staff distributed f121.0 million to regions under the
14 HIV AND AIDS RELATED HEALTH SERVICES
Figure 5
Ring fenced allocations in 1990-91
Prevention and non-treatment
Treahnent and Care 56%
Source: Department of Health.
Figure 6
HIV and AIDS allocations to regional health authorities in 1990-91 !+ogion Nw Thames NE Thames sE namer naent NorthWslfem werlMidlandi sw Thames vxbbire werser Nodhem Treatmentandcam
EarlAnglia” p ;. ;. f Million Source: Department of Health.
three main headings of treatment and care, services proportion to the population in each region to drug misusers and prevention and non-treatment aged 15 to 34 years; activities. The original allocations were calculated . prevention and non-treatment-on the as follows: basis of the general population in each . treatment and care - 75 per cent of region. expected total costs in 1989-90 allocated on 2.24 This mechanism has resulted in the the basis of the number of reportedrepc live allocations shown in Figures 5 and 6. In 1990-91 AIDS cases in each regio-region at-‘ rLthe end of octrL- 1nao. allocations to each region were up-rated by five per October 1988; cent. In 1990-91, over 58 per cent of ring fenced . services to injecting drug users-in monies were allocated to the four Thames regions.
15 HIV AND AIDS RELATED HEALTH SERVICES
Table 2
Variations in the ratio of HIV antibody positive reports to the number of people with AIDS at 31 March 1990
NW Thames 3,971 595 6.7 NE Thames 2,320 233 9.9 North Western 705 48 14.7 Trent 366 31 11.8 Oxford 346 24 14.4
Source: AIDS (Control) Act Reports.
2.25 To target resources towards treatment and crude. They told the National Audit Office that they care, the Department need an accurate estimate of were reviewing the arrangements for targeting the resources used in providing services for those resources and the system of allocation to regions. In with HIV and AIDS. In most districts the necessary district health authorities the introduction of costing and activity data were not readily available. contracts between purchasers and providers should Estimating costs was complicated by the broad make resource allocation and assumed activity spectrum of services used by HIV and AIDS levels more explicit.. patients. To remedy this, the Department commissioned a series of snapshot studies between Use of ring fenced funds 1987 and 1989 in Riverside, Oxfordshire and 2.26 In 1989-90 some authorities had difficulty in ‘Brighton Health Authorities to inform their using their allocations within the financial year: the decisions on funding (Appendix 2). Riverside and total reported surplus was fl5 million including Oxfordshire Districts have since taken steps to E9.2 million in North West Thames Region (Table generate more reliable data for monitoring local 3). This Region cited slippage on capital projects services. and the rapid rise in funding since 1985-86 as contributory factors. Some health authorities have 2.26 When allocating resources for treatment and used underspends to overcome deficits on other care, the Department assumed that the ratio of HIV activities, without approval,In these casesmonies to AIDS patients was the same in eachhealth have generally had to be repaid to the AIDS budget authority. Live AIDS case numbers were used as a in subsequent years. Underspends declared in the proxy for allocating resouces to regions. However, AIDS (Control) Act reports by districts have later ratios are likely to vary across the country (Table 2). been used, with approval, to re-imburse Furthermore, changing patterns of care and the expenditure without the provision of supporting growing need for community services may place cost information. Appendix 3 provides details of demands upon the region of residence rather than cases found in the authorities visited. the region of first report. Over time the ratio of HIV to AIDS patients may change. As the clinical 2.29 Some health authorities considered the management of patients improves, progression original guidance to have been unclear. AIDS allocations were originally intended to be a towards AIDS is slowed down; consequently the contribution towards likely costs. However, proportion of people with AIDS to those with HIV reported outturn figures indicated that allocations will decrease. for treatment and care within districts had in some instances been regarded as an expenditure ceiling 2.27 These developments have implications for by some authorities. Authorities were also confused rasourca allocation. The Department acknowledge as to whether ring fenced monies were intended to that the systems for allocating resources may be cover marginal or total cost.
16 HIV AND AIDS RELATED HEALTH SERVICES
Table 3
HIV and AIDS related services: regional health authority allocations and outturn expenditure 1988-89 to 1989-90 (Figures are at cash levels).
North West Thames 31.5 29.0 2.5 36.9 27.7 9.2 North East Thames 11.5 9.1 2.4 16.7 14.3 2.4 South East Thames 5.8 5.0 0.8 11.4 13.4 WI Trent 1.6 1.8 (0.2) 6.9 4.4 2.5 North Western 1.5 1.4 0.1 6.8 8.3 (1.51 West Midlands 1.0 1.5 CO.51 6.7 3.9 2.8 South West Thames 1.7 1.7 5.5 5.4 0.1 Yorkshire 1.0 2.1 (1.1, 5.3 5.7 (0.41 Wessex 1.3 1.2 0.1 4.8 3.1 1.7 Northern 1.3 1.3 - 4.7 4.6 0.1 South Western 0.5 0.5 4.7 4.5 0.2 Oxford 1.3 2.1 (0;) 4.2 3.6 0.6 Mersey 0.5 2.1 W3 3.4 4.0 KW East Anglian 0.7 0.9 (0.2) 3.0 2.6 0.4
Total 61.2 59.7 1.5 121.0 105.5 15.5
(a) Allocations included a 75 per cent contribution towards the expected costs of treatment and care. (h) Actual expenditure is not available. Source: Department of Health.
Monitoring the expenditure of ring fenced funds were not reconciled to estimated expenditure on identified and approved activities and some AIDS 2.30 Each health authority’s AIDS (Control) Act allocations were used for other purposes. The report must show estimated total expenditure on Department have told the National Audit Office HIV and AIDS related services. Until April 1991 the they have written to all regions providing detailed Department had placed no specific requirement on feedback on their AIDS (Control) Act reports for health authorities to scrutinise this expenditure of 1989-90 and will seek to improve the monitoring of ring fenced funds at unit level or across districts. 1990-91 reports. , 2.31 Authorities have reported difficulties in monitoring detailed expenditure at district and unit 2.33 Ring fencing is considered by health level. The National Audit Office recognise that authorities to have been crucial in enabling services g general weaknesses in financial information systems to respond to the HIV epidemic, especially in may have hindered the capture of relevant costing London. In the main districts, this funding now data. Regions such as North East Thames are constitutes a significant proportion of district encouraging the introduction of systems at district revenue-Riverside (8 per cent), Parkside (6.5 per level to identify and monitor relevant expenditure. cent] and Bloomsbury (3 per cent). In the future, districts will enter into explicit contracts with 2.32 In general, the National Audit Office found provider units. These arrangements will make it more important for costs to be effectively monitored that Departmental and health authority and controlled. The Department of Health told the arrangements for the review of ring fenced National Audit Office that the regions’ planning expenditure were weak. At the time of the National needs would be taken into account in considering Audit Office’s fieldwork, outturn figures reported in the removal of the ring fenced arrangements. If the the AIDS (Control) Act reports were subject to ring fencing mechanism were to be removed, health limited scrutiny by both the Department and authorities would need sufficient time to assess the regions. 1n some instances, ring fenced allocations impact on their services.
17 HIVANDAIDSRELATEDHEALTHSERVICES
Table 4
Special AIDS units: revenue allocations and expenditure 1988-90
Allocation 2.5 3.2 2.2 7.9 Expenditure 1.2 2.8 0.8 4.8 Surplus 1.3 0.4 1.4 3.1
Funding in Scotland on, for example, senior medical staffs’ salaries and community outreach teams, which was excluded General from reported expenditure on the Unit. In Scotland, special funding of HIV and AIDS 2.34 General AIDS allocation related services started in 1988-89. There were two elements: 2.36 The National Audit Office found that in 1989-90 all three health boards visited had l specific allocations for specialist units; underspent their allocations: l general AIDS allocations. Specific allocations were given to three boards-Greater Glasgow, Lothian and Tayside-to mver the capital and revenue costs of Greater Glasgow 1.7 1.0 developing and running their specialist units. In Lothian 1.0 0.4 addition, a general AIDS allocation was split Tayside 0.6 0.35 between all health boards on the basis of their resident populations. This allocation was in recognition of the extra burdens arising from HIV 2.37 In 1989-90, health boards reported in their and AIDS and represented a contribution towards AIDS (Control) Act reports that they had spent g8.8 the provision of services. Neither the general million out of their allocation of E12.6 million. Prior allocation nor the specific allocation for the to 1990-91, the AIDS (Control) Act reports were the specialist units were ring fenced. The Scottish only financial information the Scottish Office Home Office Home and Health Department informed and Health Department obtained on health boards ! boardsthat they had to determine their own AIDS expenditure. The Departmentnow consider , priorities and judge whether they needed to spend this inadequate for monitoring purposes, and mc~e or lass than their AIDS allocations on consequently boards were required for 1990-91 to providing AIDS and HIV services. produce an in-year statement of actual and forecast expenditure. Allocations for Specialist Units 2.35 The Scottish Office Home and Health 2.38 Results show that total expenditure by boards Department examined boards’ estimates of costs for 1990-91 is expected to have exceeded before making capital and revenue allocations for allocations by approximately El.1 million. Lothian the specialist units. The National Audit Office and Grampian expect to overspend their allocation found that prior to 1990-91 the Department had by 39 per cent (Z2.0 million) and 56 per cent (~0.4 monitored capital, but not revenue expenditure million] respectively, whilst Lanarkshire will against allocations. Between 1988 and 1990 the underspend by 86 per cent (EO.6 million) and three health boards with special AIDS units Ayrshire and Arran by 72 per cent (E0.3 million). reported significant revenue underspends [Table 4). Lothian told the National Audit Office that the 2.39 The Scottish Office Home and Health surplus was largely accounted for by expenditure Department recognised that there were problems
18 with their dual AIDS allocation system. Specific a contribution towards administrative costs, AIDS allocations directed at funding the AIDS units although some grants were made to facilitate the in the three main centres reflected available development and provision of particular services. In estimates of service needs in the board areas a number of cases funding was guaranteed over a concerned. But the method of distributing the three year period. general AIDS allocation did not fully reflect: 2.44 Additionally, both region and district health . the differences in the prevalence of the authorities as well as health boards have been virus in each of the health boards: involved in funding the provision of local voluntary services. In London, North West Thames and North I . monies that some boards had separately received for developing their specialist East Thames have had responsibility, on behalf of units; and the other Thames regions, for co-ordinating funding for hospice services provided by the Mildmay . the cost of providing care for the patients Mission and the London Lighthouse. In 1990-91, located outside specialist units. El.3 million was provided to these two bodies in addition to f150,OOO paid to a number of other 2.40 To overcome these problems the Scottish voluntary organisations. In Trent, districts planned Office Home and Health Department introduced a to spend 12 per cent (f644,OOO)of their HIV/AIDS new system for allocating AIDS monies in 1991-92. allocation on voluntary bodies in 1990-91. Some This system aims to link funding more closely to authorities were exploring ways in which non- the costs of treating people with HIV and AIDS, financial support could be given, for example, in the whilst ensuring that there are sufficient funds to form of training and accommodation. run specialist units. The new system has given additional funding to some boards, in particular 2.45 North West Thames have introduced Lothian, whilst other boards have received less procedures and criteria for funding voluntary provision commensurate with the number of known bodies and have established a panel to scrutinise HIV/AIDS cases in their areas. grant applications and make recommendations. In general, however, the National Audit Office found 2.41 The Department have recognised that further that there were many sources of funds, each with scope will exist to refine the system of allocating their own criteria for approval, allocated at different HIV and AIDS monies when more data are available times of the year. Systems for funding within health on boards’ actual expenditure. More regular authorities were often unclear. The complexity of monitoring of expenditure should enable the the current arrangements makes demands upon the Department to identify those boards in most need of voluntary sector’s managerial and administrative resources and those which are not spending the full resources. For example, in 1969-90 the Terrence amount of their allocation. Higgins Trust made 69 separate funding applications to the 33 London Boroughs and to a number of Voluntary sector funding regional and district health authorities. Since April 1991, voluntary bodies contract for services in the 2.42 Voluntary organisations in this field currently same way as statutory providers; these organisations receive funding from a range of statutory sources. provide services for people from a large number of These include the health departments, regional and health districts. Regions may also continue to give district health authorities, health boards and local voluntary organisations grants for core costs. authorities. 2.46 The Scottish Office Home and Health 2.43 Since 1985-86, the departments have Department, through health boards, fund a number provided direct funding to a number of voluntary of community-based groups who provide services bodies. These organisations, such as the London for drug users, including advice and counselling Lighthouse, Mildmay Mission, the Terrence Higgins about the risks of HIV infection. These groups, Trust and the Scottish AIDS Monitor, are which received in excess of $1 million in 1989-90, considered to have a national role in providing produce annual reports which include resource and services for those with HIV and AIDS. Grants made activity data. Subject to satisfactory performance, directly by the departments totalled about EZ current projects are guaranteed funding up to million in 1990-91. Most of these were awarded as 1993-94. HI” AND AIDS RELATED HEALTH SERVICES
Part 3: Treatment and care services
3.1 The treatment, care and support needs of (Monks Report) set up to examine genito urinary people with HIV alter as their body’s immune medicine clinics. The National Audit Office found system is gradually destroyed by the virus. A range that the regions visited were implementing the of specialties may be involved in providing hospital Working Group’s recommendations by taking steps care; these include genito urinary medicine, to improve the quality and accessibility of their infectious diseases, respiratory medicine and genito urinary medicine service. gastroenterology. Figure 7 identifies the services that infected people may need at different stages of 3.3 In Scotland, the development of services has their illness. The National Audit Office set out to had to take into account a different client mix. Of examine the arrangements made to provide, cost those cases of HIV infection where the transmission and evaluate these services. The major treatment route is known, approximately 50 per cent of those and care centres provided by the health authorities infected have a history of injecting drug use and and boards visited are described at Appendix 4. probably acquired the virus through needle sharing associated with drug injection. This group presents particular difficulties in providing services. Non Provision of services attendance rates have been as high as 36 per cent at the HIV outpatient clinics within Lothian, Tayside Hospital services and Greater Glasgow Health Boards. These boards have improved outpatient attendance by use of 3.2 People who are concerned that they have been dedicated clinics which offer flexible appointment exposed to the virus may refer themselves initially times. for counselling and testing to genito urinary medicine or specialist HIV outpatient clinics. Both 3.4 Until recently services have been developed the Department of Health and the Scottish Office mainly in a number of centres by key clinicians to Home and Health Department have emphasised to meet the growth of infection in their area. For health authorities and boards the importance of example, in England, the treatment and care of genito urinary medicine in combating the virus. In AIDS patients has been concentrated mainly in 1988, the Department of Health recommended to hospitals in London: The Middlesex Hospital health authorities a report by the Working Group (Bloomsbury), St Mary’s Hospital (Parkside) and
Figure 7
Care for people with HIV infection
HIV Asymptomatic (1) 0 0 0 Symptomatic 0 0 0 0 AIDS Acute Infection/Other Problems 0 0 0 0 Convalescence 0 0 0 0 Terminal Care 0 0 0 0
Source: National Audit Office fieldwork-based on a diagram published by Prof. M W Adler. Note [I): persons infected with HIV but not showing symptoms. HIVANDAIDSRELATEDHEALTHSERVICES
Charing Cross and Westminster Hospitals Care in the community (Riverside). Over 35 per cent of all AIDS cases in 3.9 Health authorities and boards have recognised England have been reported by these three districts. that care in the community may be an effective way But, in March 1990, over 65 per cent of AIDS of reducing pressure on hospital services. For patients treated within these districts lived outside example, St Mary’s (Parkside) believe that the the authorities boundaries. expansion of community services was a major cause of the reduction in the average length of inpatient stay, during 1969-90, from 13.2 to 7.3 days. 3.5 The services offered by most English health authorities are less well developed than those offered in Bloomsbury, Parkside and Riverside. Patients are consequently attracted to the London 3.10 To meet the problems of cross boundary flows districts by their reputation for high quality care. St Mary’s [Parkside) and The Middlesex Both North East Thames and North West Thames (Bloomsbury) Hospitals have developed multi- Regions are finding that large inflows of AIDS disciplinary teams. The teams’ prime objective is to patients are putting pressure on The Middlesex, St activate local services, especially outside the Mary’s and Westminster Hospitals. district, such as primary care teams and local authority services. Riverside District, Lothian and Greater Glasgow Health Boards do not have a designated AIDS team. Both Riverside and Lothian 3.6 North East Thames Region told the National have employed a medical officer designated to Audit Office that they predicted the need for at improve the continuity of care, for example, by least 50 additional AIDS beds in the Region by 1993. encouraging the greater involvement of general However, at The Middlesex Hospital (Bloomsbury) practitioners. Most of the health authorities and the AIDS Steering Group consider that no more boards visited relied on district nurses to provide beds can be made available. The Region is therefore care for HIV/AIDS patients. focusing attention on developing services outside Bloomsbury, by using joint consultant posts and developing the skills of primary health care teams. Similarly, North West Thames has tried to develop 3.11 General practitioners are experienced in services outside Parkside and Riverside. A key providing community based care, including element in their strategy has been developing terminal care. Some general practitioners in the past genito urinary medicine services in districts which have been reluctant to play a full part in treating did not previously provide this care. AIDS patients and infected drug users. A joint report by the Universities of York and Hull in 1991 stated that 34 per cent of people with HIV/AIDS 3.7 In Scotland, approximately 90 per cent of the said that their general practitioner was not aware of people who are known to have the virus were their HIV status. Most people with HIV/AIDS said tested within the Edinburgh, Glasgow and Dundee their requirements were met by an HIV clinic; areas. Specialist AIDS units have accordingly been others assumed that their general practitioner established in the three cities with the largest lacked knowledge or sympathy. number of infected people: Ruchill Hospital [Glasgow), the City Hospital (Edinburgh) and King’s Cross Hospital (Dundee]. By 1994, Lothian and 3.12 In response to the expansion of care in the Greater Glasgow have estimated that they will community for HIV/AIDS patients, the Royal require 107 beds and 42 beds respectively, almost College of General Practitioners have a working three times the current number available. This is party examining the role of the general practitioner mainly due to the expected increase in the number and the primary health care team in the diagnosis of drug users infected with HIV. and, more importantly, the management of HIV/AIDS patients. The Department of Health have initiated a range of projects aimed at providing 3.8 As more effective drug treatments have been information and training for general practitioners. developed and medical staff have gained greater The Faculty of Public Health Medicine has also experience of caring for patients with AIDS/HIV, produced practical guidelines for public health health authorities and boards have expanded the physicians on how to increase the role and amount and types of treatment given on an involvement of primary care teams in the treatment outpatient and day care basis. of AIDS patients.
21 HIV AND AIDS RELATED HEALTH SER”lCES
3.13 Specialist teams and liaison officers have had Costing of services some success in involving general practitioners in the treatment and care of patients with the virus. 3.17 Health authorities, boards and hospitals need For example, Bloomsbury report that involvement to know the cost of providing AIDS and HIV of primary health care teams in providing services to: domiciliary care for people with HIV has risen from . enable them to predict the resources 35 per cent at the beginning of 1988 to 90 per cent required to provide care in future years: in 1990. . inform decisions concerning the way in Hospice care which care is provided; 3.14 Hospices can provide patients with . assist the development of future contracts convalescent, respite and terminal care, thus for the purchase and provision of services. reducing the demand for hospital inpatient beds. The costing systems at most health authorities and The three main districts in London do not have boards visited were unable to identify the cost of their own facilities but fund voluntary groups, such providing treatment and care to a particular AIDS as Mildmay Mission and London Lighthouse, to patient or group of AIDS patients. provide hospice care. Mildmay Mission consider that specialist palliative services for treating 3.16 The Department of Health, two of the pregnant women and children are not currently authorities and one of the boards visited had available within health and local authorities, and undertaken studies to identify the costs incurred in are planning to open a unit providing such care and providing HIV and AIDS services [Appendix 2). accommodation for families. In Scotland, hospice Generally the results are not directly comparable care for people with AIDS is provided by the because there were differences in the patterns and Waverley Care Trust which has received funding type of care provided, and the bases and timing of from the Scottish Office Home and Health the castings varied. A study at Riverside in 1989-90 Department, Lothian Health Board and other showed that the cost of providing inpatient care for statutory bodies. an AIDS patient (excluding drugs) was f334 a day on the general wards at Charing Cross Hospital, 30 Developing services per cent higher than on the dedicated wards at Westminster Hospital (E255). At the time of the 3.15 The health authorities and boards visited National Audit Office investigation, the District reported that they have been able to meet demand. were examining the reasons behind these The major treatment centres, in conjunction with differences. voluntary bodies and local authorities, provide a comprehensive range of services for patients. 3.19 Advances in the use of drugs for the treatment of HIV/AIDS patients have prompted a 3.16 The Day Report predicts that by 1993 the HIV significant shift in service needs from inpatient to infection in half the newly reported cases could community, outpatient and day care services. Such have been passed on through heterosexual contact developments have had a dramatic effect on costs, or the sharing of contaminated needles by drug but have not been continuously and I users. This will have implications for developing comprehensively monitored. For example, new and existing services. The initial results of the Zidovudine, a drug which slows down the anonymised surveys conducted by the health destruction of the body’s immune system, was departments also indicate that the spread of the initially licensed for treatment of people with HIV disease by heterosexual contact is not being who were ill. However, in 1990 the licence was contained. As a result, the Department of Health set extended to cover people with the virus who were up an AIDS Action Group in May 1991 to seek to asymptomatic (persons infected but not yet showing reduce the future incidence of HIV/AIDS in areas symptoms). Authorities and boards with large of increasing prevalence. This group will focus on known HIV populations were concerned about their access to local services, local prevention and ability to meet the additional costs of providing educational initiatives. At the same time, the Zidovudine to patients who had not yet developed Scottish Office Home and Health Department set up symptoms. Trent Region had calculated that if they an AIDS Task Force to consider what further started to prescribe Zidovudine to their patients measures can be taken in Scotland to reduce the who do not have symptoms, it could increase their spread of HIV and AIDS, and to ensure that services Zidovudine bill by over f700,OOO to i935,OOO a year. and initiatives at national and local level are This is equivalent to 12 per cent of their 1990-91 provided and co-ordinated effectively. AIDS allocation.
22 Evaluation of services AIDS (Control) Act Reports 3.23 The health departments, health authorities 3.20 The Department of Health have sponsored a and boards need information on which they can project at Parkside to evaluate the effectiveness of assess the needs of their population and plan and treatments as well as their cost. The Department are manage services to meet those needs. The principal also funding an independent evaluation of the sources of information are reports prepared under services provided by London Lighthouse and are the AIDS (Control) Act 1987. The Act prescribes the planning an evaluation of the services of the inclusion of: Mildmay Mission. the known number of HIV seropositive people and people with AIDS in the area of the authority or board: 3.21 The Department of Health required regions to establish by March 1991 [now March 1992) a a report of services and facilities; regional research programme to determine the cost the number of staff employed; effectiveness of local HIV prevention and treatment and care initiatives, and to measure the quality of expenditure on HIV and AIDS related care provided. The National Audit Office found that services. some health authorities visited had or were developing a programme for evaluation. For 3.24 The reports have a dual purpose-to inform example, North East Thames Region planned to the Secretaries of State of the progress and commit up to two per cent of their AIDS allocation treatment of the disease, and to enable departments with the objective of identifying good practice as and regions to monitor and review services. well as gaps in service provision. It was developing a programme to evaluate hospital based services. 3.25 The National Audit Office found that in Specific evaluation exercises found by the National general health authorities and boards needed more Audit Office included: guidance on the format and content of the reports and would welcome more feedback from the l Riverside District had examined the departments. There was sometimes a lack of outpatient and day care services provided uniformity and consistency in the information at a specialist HIV clinic, and the care contained in these reports. For example, there was given to dying and bereaved people on a difficulty in gathering accurate manpower data and dedicated AIDS ward. Its business plan on occasions the reports reflected only direct contained proposals to evaluate alternative staffing numbers. Parkside stated that to facilitate models of care; comparison there should be standardised l Lothian Health Board had identified that manpower, activity and finance data. The some patients had difficulty travelling to departments recognised the difficulty in collecting hospital outpatient clinics and they had manpower data but considered the reports to be therefore developed more accessible most useful. The Department of Health and Scottish clinics. Office Home and Health Department issued new guidance in April and July 1991, respectively, which asked for additional finance and service information. 3.22 In general, less emphasis had been placed on the evaluation of inpatient services. The method of The National Health Service Reforms providing inpatient care and the length of inpatient stay varied. Most of the major treatment centres 3.26 Since 1 April 1991, in England, purchasers of provided care for patients in dedicated wards health care services (for example, health although some hospitals relied on general wards authorities) have been separated from providers (for (for example Charing Cross Hospital). In Riverside, example, hospitals). There are now service average length of inpatient stay on the dedicated agreements between the two, based on an agreed wards at Westminster was 13 days while in the level of charges. For 1991-92 the Department general surgical wards at Charing Cross it was 18 decided that funding arrangements for AIDS days. The length of inpatient stay reflected services would remain unchanged. However, as differences both in the needs of the patients and the with other services, the reforms will eventually local model of treatment and care; but there was no have consequences for HIV/AIDS services. evaluation of the benefits of the different Guidance on how regions and districts should arrangements, although some aspects might have prepare for these changes has yet to be issued. In been covered by medical audit procedures. the absence of guidance, health authorities visited
23 HI” AND AIDS RELATED HEALTH SERVICES by the National Audit Office were concerned about with the need to provide evidence of patient the longer term funding and provision of HIV and residence to the charged district. The Department of AIDS services. Health authorities were also unclear Health’s AIDS Unit has established a national as to whether pump priming of services outside the working party to develop contracting on a district of main centres would continue. The Department of residence basis for HIV/AIDS. Health have funded a project at Parkside to clarify , the purchaser/provider relationship for HIV and 3.28 In Scotland, the issue of how the reforms I AIDS related services. Riverside and Parkside would affect these services is still being addressed. Districts have generated cost data which will enable The question of contract arrangements for AIDS them to purchase AIDS services on a contract basis. services will be covered in guidance to be issued in 1992-93. 3.27 The current major provider units treat a large proportion of non-resident self referred patients. Given the open ~CCBSSand confidential nature of 3.29 Voluntary bodies were also uncertain how the the client population, it may be difficult to reforms would affect them. The introduction of constrain activity to the contracted level. contracts with each purchaser having its own Furthermore, services are diffused throughout specification of what is required from the voluntary many areas of acute, community and mental health body could create difficulties in service provision. units. Therefore, provider units may not be in a And there would also be similar problems in position to identify all activity or costs, and the confirming the district of patient residence and in strict requirement for confidentiality may conflict identifying costs.
24 Part 4: Local prevention initiatives
Introduction 4.2 Local campaigns have been introduced to reinforce national prevention campaigns and to 4.1 There is currently no vaccine against HIV, and encourage and sustain amongst targeted groups, the development of a cure for AIDS is not expected changes to behaviour which carry a particular risk for several years. The health departments recognise of HIV infection. Examples of prevention initiatives that preventive measures are an important part of are in Table 5. The National Audit Office therefore the strategy against HIV infection and AIDS, and set out to examine health authorities’ progress in remain the only means currently of controlling the planning and implementing local measures and spread of infection. services for this important aspect of HIV prevention.
Table 5
Examples of prevention initiatives
Lothian Health Board Take Care: A wide ranging and long running public education campaign. It was aimed at raising awareness of HIV in the general public. It had a highly recognisable logo which appeared in a large number of public and social venues. This was designed to keep thoughts of HIV at the forefront of peoples’ minds and have long term impact.
Greater Glasgow Health Board Needle Exchange Schemes: These allow drug users to exchange used needles and syringes for sterile ones. The schemes have been developed in areas of known high levels of drug use, such as large housing estates. These exchanges allow easy access to sterile equipment. Opportunity is also made to counsel and educate injecting drug users about safer practices.
Bloomsbury Health Authority CLASH-Central London Action on Street Health: This is an outreach service introduced to take the health education message to those whose activities, such as prostitution and injecting drug use through needle sharing, place them at particular risk of exposure to HIV infection. It also provides essential materials such as condoms and sterile needles and syringes to enable these people to maintain safer lifestyles. * Riverside Health Authority Situation: A board game designed to be used in schools which through play, introduces young people to HIV and AIDS and provides advice on how to protect themselves. It puts the children into hypothetical situations which test their knowledge and allow them to learn the “right” answer or response.
Parkside Health Authority Royal Court Young People’s Theatre: This was a play about HIV and AIDS issues acted by young people from the local community and performed in front of a young audience. This was followed up by discussions amongst the audience afterwards over what they had learnt.
British Medical Association The British Medical Association have organised national education activities including: (1) the publication of “AIDS and You-An Illustrated Guide” in association with the Health Education Authority-aimed at those with a professional interest in HIV; and (2) “The AIDS and You Educational Game”- a learning package aimed at schools. Some of these activities were funded by the Department of Health.
25 H,V AND AIDS RELATED HEALTH SERVICES
Prevention strategies Targeting prevention resources
4.3 The Department of Health have asked regional 4.6 Department of Health prevention allocations health authorities to agree a regional plan by 31 and the general allocations in Scotland are based on March 1992 (originally by March 1991) for the the population within each authority and board. In provision of HIV/AIDS related services including 1989-90, the Department of Health allocated E14 prevention, in conjunction with district health million to health authorities as a contribution authorities, family health service authorities and towards developing prevention initiatives: actual local authorities. Similarly, district health expenditure exceeded U3.5 million. In Scotland, authorities are expected to have agreed with health boards used El million in 1989-90 to relevant statutory and voluntary agencies a three- undertake preventive measures. year programme of community-based HIV prevention initiatives aimed at encouraging 4.7 The National Audit Office found that actual sustained behavioural change. The Department of expenditure on local prevention services varied Health highlighted various target groups, including: significantly within district health authorities and health boards. In North East Thames Region, annual . attenders at genito urinary medicine district health authority expenditure on HIV clinics; prevention ranged from fO.10 (Mid-Essex) to f2.50 a injecting drug users; (Bloomsbury) per head of population. Expenditure in Lothian and Greater Glasgow was approximately l men who have sex with men; El.00 and fO.30 a head respectively. Local l wmnen and men working as prostitutes. circumstances, the classification of expenditure, and the amount health authorities themselves The Scottish Office Home and Health Department contribute from their own budgets, affect total gave health boards guidance on local HIV recorded expenditure on prevention. London and preventive initiatives in May 1989. other high prevalence authorities tended to spend a higher amount per person and, generally, had a mme comprehensive range of prevention initiatives. 4.4 Health authorities and boards experience difficulty in gathering basic data on the make up of HIV Prevention Co-ordinators their local population at risk, for example the number of injecting drug users. This in turn creates 4.8 In 1989, the Department asked each district problems in planning local prevention programmes. health authority to appoint an HIV Prevention Co- ordinator. The main focus of the Co-ordinator’s work is to encourage and monitor the development 4.5 However, all authorities and boards visited by of local prevention initiatives, and the development the National Audit Office had developed or were of a joint health, local authority and voluntary preparing a prevention strategy. These strategies sector strategy for HIV prevention, rather than field emphasised the need to: work. . remwe any stigma associated with HIV infection: 4.9 HIV Prevention Co-ordinators had been nominated in nearly 150 of the 190 district health . introduce staff training and raise staff authorities in England, sometimes with dual awareness; responsibility such as Director of Health Promotion. . direct services towards the young, the Two regions (North East Thames and Oxford) told sexually active, drug misusers and the National Audit Office that in scme of their marginalised groups in the community; districts the authority of Co-ordinators was weakened, as they were unable to control l introduce initiatives appropriate to local prevention budgets or properly develop HIV related needs. initiatives. In Scotland, the management of HIV In Bloomsbury, the District strategy identified a prevention was part of the AIDS Co-ordinator’s role. range of health and other services, including health centres and family planning clinics, which could be Services for drug users used to promote the prevention message to specific risk groups. In North West Thames Region, an 4.10 Sharing infected needles is one of the main essential part of their prevention strategy was the routes of HIV infection transmission, and “HIV Project” designed to foster a resource and particularly high concentrations of HIV infected training centre and links with other agencies. drug users mcur in London and Scotland. In
26 Scotland, the majority of people identified as HIV national HIV/AIDS Health Promotion Forum which positive have contracted the infection through includes representatives from the statutory and sharing injecting equipment. In 1986, the voluntary sectors. In Scotland, health boards have McClelland Report in Scotland recommended the close links with the Health Education Board for introduction of schemes which allow drug users to Scotland. exchange used needle and syringes for sterile ones. This was endorsed by the Advisory Council on the 4.14 Voluntary organisations’ early involvement in Misuse of Drugs in their report “AIDS and Drug prevention activities, such as the Terrence Higgins Misuse Part 1” published in 1966. The report said Trust and Scottish AIDS Monitor, helped to inform that existing pilot schemes for exchanging needles people in certain target groups about the existence and syringes were inaccessible and unattractive to and nature of AIDS and HIV. They continue to the vast majority of drug users. Tayside Health operate and collaborate with prevention initiatives Board were considering fresh proposals for needle at both a national and local level. Health boards and syringe exchanges in the light of the success of have worked with regional councils to finance and exchanges operating in the Lothian and Greater establish prevention projects such as health Glasgow Health Board areas. promotion programmes, and provision of specific services for drug misusers and prostitutes. In 4.11 In 1990 health departments and health London, there was less evidence of collaboration authorities established a new database which was with local authorities on prevention. aimed at improving significantly the data on drug trends and the number and characteristics of drug Evaluation of local prevention initiatives users attending drug misuse services. 4.15 IIealth authorities commented upuu the difficulties inherent in evaluating the effectiveness Integration of local prevention initiatives of their prevention initiatives. A common difficulty with other agencies they faced was in forming accurate details of the changes in risk behaviour. This was complicated by 4.12 The health departments are responsible for having a highly mobile and diverse population, and co-ordinating the strategy on public education about by the need for confidentiality about sexual activity HIV infection and AIDS. The Health Education and drug use. To assist appraisal the Health Authority organise public education campaigns Education Authority and the Faculty of Public across the United Kingdom. Most authorities Health Medicine have both produced guidance on commented that the Health Education Authority evaluating local initiatives. This guidance includes were unable to give comprehensive advance details the need to establish appropriate proxy outcome of their national campaigns. The Department of indicators such as: Health told the National Audit Office that advance notice was not always practicable; some campaigns l numbers and types of calls to helplines; necessarily had to be at short notice. . needles and syringes exchanged; . trends in demand for HIV antibody testing. 4.13 Local Prevention Co-ordinators often could not complement the Health Education Authority In Scotland, the Health Education Board for campaigns or support their momentum. Prevention Scotland (and before that the Scottish Health teams reported that they met significant delays in Education Group) have carried out evaluation of receiving promotional material from the Health HIV/AIDS education material. Greater Glasgow and Education Authority. The Department of Health Lothian Health Boards have also developed told the National Audit Office that they were mechanisms for monitoring and evaluating their seeking to strengthen links between the national services for drug users. In London, there has been and local campaigns. To assist this process the some evaluation, for example the Central London Health Education Authority host meetings of a Action on Street Health project.
27 Glossary of terms AIDS Acquired Immune Deficiency Syndrome is caused by a virus (HIV--see below]. This virus weakens the body’s immune system. As a result the body is more likely to get illnesses which it could normally fight off easily. These illnesses can be serious and fatal. Asymptomatic Showing no symptoms [of HIV infection). Gastroenterology Specialty which treats stomach and intestinal conditions. Genito urinary Specialty which treats sexually transmitted diseases and other conditions medicine affecting the genito urinary tract, and which provides education on maintaining sexual health. HaemophiIia Hereditary disorder in which the blood clots very slowly, due to the deficiency of one of the clotting factors. Haemophiliac Person with above condition. HN Human Immunodeficiency Virus. The causative agent of AIDS, which infects and destroys certain blood cells crucial for the effective functioning of the immune system. HN antibody The presence of antibodies to HIV in a person’s blood (indicating infection with positive (seropositivel HIV).
Injecting drug An individual taking drugs through intravenous injection. user Needle and syringe A service to allow injecting drug users to freely obtain sterile injecting exchange scheme equipment and safely dispose of used equipment. Outreach service Provision of services (often used in reference to prevention services) in the community to access people who are difficult to reach. Respiratory Specialty which treats chest conditions. medicine symptomatic Showing symptoms (of HIV infection). Zidovudine (AZTI A drug to inhibit HIV and delay the progression to, or of, AIDS.
Organisations Communicable Part of the Public Health Laboratory Service which carries out epidemiological Disease surveillance of HIV/AIDS through voluntary reporting. Surveillance Centre London Lighthouse A centre for people with HIV and AIDS, offering respite, convalescent and terminal care: along with a range of therapies, support groups and training. MacFarlane Trust A Trust established to distribute compensation monies to haemophiliacs infected with HIV. Mildmay Mission A centre which offers rehabilitative, convalescent, respite and terminal care for people with AIDS. OXAIDS A voluntary charity providing HIV related care and education throughout Oxfordshire. Terrence Higgins A national voluntary organisation providing education on HIV and AIDS and Trust support services for people affected by the virus. Scottish AIDS A voluntary organisation providing education on HIV and AIDS through direct Monitor personal contact and public campaigns in Scotland. Waverley Care An organisation to raise funds for and manage a hospice in Edinburgh for people Trust with AIDS.
28 HIV AND AIDS RELATED HEALTH SERVICES
Bibliography
Part 1: Introduction and background Problems associated with AIDS, Third Report from the Social Services Committee, Session 1986-67, Cm 182. Problems associated with AIDS. Response by the Government to the Third Report from the Social Services Committee, Session 1986-67, Cm 297. AIDS, Seventh Report from the Social Services Committee, Session 1988-89, Cm 202. AIDS, Response by the Government to the Seventh Report from the Social Services Committee, Session 1988-89, Cm 925. Publicity Services for Government Departments, Session 1989-90, HC 46.
Part 2: Planning and funding arrangements Tayler Report (Scotland), Report of the National Working Party on Health Service Implications of HIV infection, May 1967. Cox Report, Short-term prediction of HIV infection and AIDS in England and Wales, 1988. Day Report, Communicable Disease Report, January 1990, Public Health Laboratory Service. McClelland Report, Projections to the end of 1993, Report of a Working Group convened by the Chief Medical Officer Scottish Home and Health Department. HIV and AIDS, Progress and Development in Social Services Departments, Social Services Inspectorate 1990.
Part 3: Treatment and care services Monk Report, Report of a working party established by the Department of Health to review the work of genito urinary medicine clinics. HIV/AIDS and Social Care, Universities of York and Hull, March 1991. AIDS/HIV Planning Advice for Public Health Physicians, Guidelines for Health Promotion Number 22, Faculty of Public Health Medicine, November 1969.
Part 4: Local prevention initiatives Advisory Council on the Misuse of Drugs. AIDS and Drug Misuse Part 1, 1988. Education of AIDS Health Promotion Programmes, Health Education Authority, AIDS Programme Paper No. 7, 1990. Information for Planning and Monitoring HIV Services, Guidelines for Health Promotion Number 26, Faculty of Public Health Medicine, May 1990.
29 Appendix 1
Summary of National AIDS Public Education Campaigns
The responsibility for general public education campaigns about HIV and AIDS passed from the Department of Health to the Health Education Authority in October 1987. Public education about the risks of HIV in relation to injecting drug misuse remains the responsibility of the Department of Health. Campaign Focus and Nature 1986 General Press advertising targeted at campaign young people. Early 1987 “Don’t Die of Mass media campaign, including Ignorance” leaflets to all UK households giving basic information. Early 1987 National AIDS Introduction of helplines to Helplines provide free information to the public. Personal advice and dial and listen taped message services also available in ethnic minority languages Early 1987 “Don’t Inject Campaign identifying the risks AIDS” of HIV infection from sharing drug injecting equipment. The risks of HIV continue to be covered within the wider drug prevention programme. February 1988 Risks of HIV Media campaign targeted at and information young people. on protection Spring 198%Summer 1990 Risks of HIV Separate campaigns aimed at abroad business travellers and holiday makers. December 1988-Spring 1989 General The general press and the campaigns on English language ethnic press risks of HIV were used to keep the general public informed of HIV and AIDS. March 1989 and Safer sex Leaflets, posters and the gay continuing press used to provide information about, and encourage, safer sex practices within the gay community. April 1989-Spring 1990 Risks of HIV Campaign targeted at young people. December 1989 World AIDS Day Support provided by press advertising. Spring 1990 Transmission Television and national press and protection campaign using experts to give factual information.
30 Spring 1990 Risk of Introduction of adverts, unprotected supported by a telephone helpline, SeXUal targeted at men who have sex intercourse with both men and women.
December 1990~Summer 1991 Risks of HIV; Television and radio campaign promoting featuring people who are HIV condoms positive, and cinema advertising aimed at normalising discussion and use of condoms by young people.
Campaign work has also included educational material for groups, such as the hearing impaired and the blind, who are not reached effectively by the national campaigns. Leaflets have also been produced for professions involving accidental or deliberate skin piercing eg tattooists.
Other Government departments, such as the Home Office, the Department of Education and Science and the Ministry of Defence, have also developed HIV/AIDS educational materials related to their particular spheres of interest.
31 Appendix 2
Summary of AIDS costing studies
Since 1987-88, the Department of Health and some of the health authorities and boards visited have carried out studies which examine the cost of providing AIDS services. It is not possible to compare directly the results of these studies because tbe method and basis of costing services varies and because the patterns and type of care provided have altered over time.
Authority Date Cost of providing AIDS services per patient Department of Health sponsored studies Riverside 1987-88 +x4,671 per year (included E~,ZOOfor Zidovudine) Oxfordshire 1988-89 f17,OOO per year Brighton 1989-90 f20,OOO per year
Studies initiated by health authorities and boards Parkside 1987 f27,OOO per year (included E5,OOOfor Zidovudine) Riverside 1989-90 f25,OOO per year l 5%~ a day at Westminster, plus E76 for drugs: l X334 a day at Charing Cross, plus E27 for drugs. Parkside 1990-91 l E281 a day at St Mary’s, excluding drugs; . f190 a day at The Central Middlesex, excluding drugs. Greater Glasgow 1990-91 E308 a day including drugs on a dedicated AIDS ward.
32 Appendix 3
The use of ring fenced funds
Examples of funds used for other purposes
North West Thames Region 1989-90 1. As a result of in-year financial pressures, and in particular capital over-commitments deriving from a depressed property market, Z8.5 million was vired from the AIDS budget of E36.9 million to the Regional Capital Programme. The AIDS (Control) Act report for 1989-90 explained the reasons for this decision and reported that all districts had received the level of resources requested for that year. 2. In November 1990, the Department asked the Region to account for their use of ring fenced funds. In January 1991, the Region agreed to repay f8.5 million to the AIDS budget in equal instalments over two years, 1991-92 and 1992-93. Oxfordshire District Health Authority 1989-90 3. Management removed EO.6 million from the District’s AIDS budget of SO.97 million to help overcome financial difficulties. Following press reports and enquiries from the Department, the District agreed to repay the borrowed monies during the 1990-91 financial year. For AIDS and HIV related developments to proceed as planned in 1989-90, the Region loaned the District an additional sum for these services. North East Thames Region 1989-90 4. Management borrowed f0.5 million from the AIDS budget to help offset the Region’s capital deficit. This will be repaid in 1990-91 and is earmarked for a specific project. West Berkshire Health Authority 1990-91 5. In 1990-91 the District used f120,OOO of their AIDS allocation for other purposes, including the purchase of new premises for health promotion and information services. At the time of the National Audit Office’s fieldwork, Oxford Region had queried this use of funds but had received no assurance that these monies would be repaid. Subsequently, Oxford Region have asked for the money to be repaid. Examples of funds used to offset past expenditure without the provision of supporting cost information Bloomsbury Health Authority 1989-90 6. For the 1989-90 financial year, Bloomsbury declared an underspend of f 720,000 in their AIDS (Control] Act report. In later discussions with North East Thames Region the Authority stated that the published figures were probably an underestimate of the true cost of providing services because they had omitted to include the cost of inpatient services at The Middlesex Hospital. The District considered that these undeclared costs would probably amount to more than the declared underspend but could provide no detailed castings. The Region accepted this explanation and allowed Bloomsbury to use these monies to defray expenditure incurred in 1989-90. North Western Region 1989-90 7. In 1989-90 funding was provided to districts to reimburse expenditure incurred during 1988-89 for HIV and AIDS services. The Region asked districts to identify the costs of providing treatment and care services, and for controlling infection. Bids were scrutinised and districts compensated for expenditure amounting to f1.5 million. 8. Given the difficulty in identifying true costs it is doubtful whether the retrospective bids by the districts were based on a sound assessment of costs. Source: Information obtained by the National Audit Office at health authorities.
33 HI” AND ADS RELATED HEALTH SERVlCES
Appendix 4
Summary of service provision at main treatment centres in England and Scotland
Bloomsbury Health Authority
At 31 March 1990, Bloomsbury were treating 166 people with AIDS. Inpatient Outpatient/Day Care Community Care At December 1990, care was During 1989, there were 4,080 Specialist multi-disciplinary concentrated in The Middlesex attendances at the genito Community Care Team, Hospital’s two dedicated urinary medicine clinic at James including medical and nursing wards, which have a total of Pringle House, and 600 staff and psychologists. The 27 beds. attendances at the University Team worked with generic College Hospital. Day care primary care providers. provided at The Middlesex Up to.March 1990, the Team Hospital. had cared for 142 people.
Park.+ide Health Authority
At 31 March 1990, Parkside were treating 285 people with AIDS. Inpatient Outpatient/Day Care Community Care At December 1990, care was During 1989-90 there were 8,424 Specialist AIDS Home Care concentrated in St Mary’s outpatient and 364 day case Team comprising nurses and a Hospital. Patients used 24 beds attendances at St Mary’s general practitioner acting as in dedicated wards and 6 general Hospital, and 177 outpatient and case managers. The Team beds. There were also two 85 day case attendances at the worked with generic primary dedicated beds planned at the Central Middlesex Hospital. care providers. Nursing Central Middlesex Hospital for care at home is provided 1991-92. through the district nursing service. Up to March 1990, the Team had cared for 439 clients.
Riverside Health Authority
Up to December 1989, 866 people with AIDS received treatment within Riverside; of whom 401 had died. Riverside were treating 389 people with AIDS at 31 March 1990. Inpatient Outpatient/Day Care Community Care At December 1990, Westminster During 1989-90 outpatient care Care provided by generic Hospital had two dedicated wards was concentrated at the dedicated district nursing service. A with a total of 28 beds. During HIV clinic at the Kobler Centre designated officer was 1989-90 Charing Cross provided (15,265 outpatient and 2,547 day responsible for developing 1,671 inpatient days in general case attendances). Care was also continuity of care. wards. provided at Westminister Hospital (7,386 outpatient) and Charing Cross Hospital (8,212 outpatient and 856 day case). In addition there were 5,582 outpatient and 1,208 day attendances at other sites.
34 Lothian Health Board
At 31 March 1990, Lothian were treating approximately 600 people with HIV, and 53 people with AIDS. Inpatient Outpatient/Day Care Community Care At December 1990, the City Care was concentrated at the City Specially trained district and Hospital treated patients on Hospital’s infectious diseases community psychiatric nurses infectious diseases wards; clinics and at the Royal provided care to patients and up to 25 beds were used. The Infirmary’s genito urinary also trained generic district Royal Infirmary provided care medicine clinics. nurses to provide care. A on general wards. A designated officer was used to dedicated 15 bad ward is develop links with general being built at the City practitioners. Hospital.
Greater Glasgow Health Board
At 31 March 1990, Greater Glasgow were treating approximately 180 people with HIV, and 15 people with AIDS. Inpatient Outpatient/Day Care Community Care At December 1990, Ruchill Outpatient and day care was A specially trained district Hospital provided care in a concentrated at Ruchill Hospital. nurse provided care to dedicated 15 bed ward and also patients and also trained on infectious diseases wards. generic district nurses to provide care.
35