COMMISSIONING XXXX
Growing older positively: The challenge of commissioning for an ageing HIV population
Matt James, research fellow at think tank 2020health, and its chief executive Julia Manning, argue that the commissioning process has been fractured by distinguishing between the treatment and prevention of HIV.
A
merican comedian George Burns may have quipped, “You can’t help getting older but you don’t have to get old”, but the question remains: when does someone become ‘older’?
To many people, the age of 50 may not seem to be ‘old’; but increasingly 50 is being used to record and analyse statistics on ‘older’ people living with HIV. In 2012, one in four adults who were living with an HIV diagnosis in England were aged 50 years and over. Older people are the fastest-growing group in the UK who are living with HIV and it was estimated that in 2012, 24,510 people living with HIV in the UK were aged 50 or over. These numbers are set to double over the next five years.
Generally those people aged 50-plus who are living with HIV fall into two general groups:
• Those people who acquired HIV early on in their life and who are living longer as a result of effective therapies and treatment • Those people who acquire HIV later on in life
More people than ever before are surviving with HIV as a result of the advances in effective treatment. Some of the latest research in this area indicates that in the UK, life expectancy for people who are HIV positive and who are on successful treatment programmes is now considered the same as someone without the condition.
Despite these advances however, older 42 | national health executive Nov/Dec 14
people with HIV remain at a disadvantage in comparison to their peers. From poor levels of health to access to social care and financial security, the older person living with HIV faces significant challenges. The interaction between HIV and ageing presents highly complex clinical challenges, partly because the disease and conditions associated with ageing present earlier or more severely in people who also have HIV.
Increased life expectancy, with the associated above-average risk
for cardiovascular,
metabolic, bone and neurological problems, are layered on top of an HIV diagnosis which is already a complex medical condition to manage and treat. This compounding challenge calls for the need to review the way HIV care and treatment are designed, managed and delivered.
One of 2020health’s recent reports, ‘Growing older positively’, undertook such a review with the aim of contributing to the ongoing conversation on this important issue. From our research we identified several key challenges, five of which are discussed below, which need to be addressed if everyone with HIV is to live a long and fulfilled life with appropriate care and support.
a) Commissioning of treatment and prevention
The main strengths of the new commissioning arrangements for the treatment and prevention of HIV are perceived to be that there is now
a national and robust service specification for HIV and that specialised services are now clinician-led. This allows for expert and professional input to help feed into and shape decision-making as well as, theoretically, offering standardisation of care across England.
In contrast, there is a perception that the commissioning process has been fractured by distinguishing between treatment and prevention. By dividing up the commissioning of treatment and prevention, and assigning responsibility to different bodies, there is concern that the two will not work in tandem and support one another. Prevention measures need to have a more clearly defined place in the current commissioning structure, aside from the immediate value they bring to the NHS.
Perhaps in recognition of these weaknesses, Public Health England brought out its National Framework for HIV, Sexual and Reproductive Health Commissioning, first published in November 2013 and updated in September 2014, aiming to bring together the commissioning responsibilities of local government, CCGs and NHS England.
The new arrangements need time to bed-in and an appropriate evaluation must take place before any conclusions are drawn, but consid- eration needs to be given to coordinating the separate services of treatment and prevention, as this is clearly an unhelpful division. There is a risk that splitting responsibilities according to treatment and prevention could create a gap
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100