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HIV Treatment

Volume 624: debated on Wednesday 29 March 2017

[Mrs Anne Main in the Chair]

Before I call Mike Freer to move the motion, I want to say that our thoughts are with the victims of last Wednesday’s atrocities. I do not think that the House is pausing in its proceedings, but our thoughts are with them today.

I beg to move,

That this House has considered the all-party parliamentary group report Impact of Health and Social Care Act on HIV treatment.

I associate myself with your comments, Mrs Main, which are exactly right, and it is a pleasure to serve under your chairmanship. I also put on the record my appreciation of the Minister and other colleagues, but especially the Minister, who has been extremely supportive of the all-party parliamentary group on HIV and AIDS and who has always been helpful when I have raised issues to do with HIV/AIDS. I am grateful, too, to other Members on what is a busy day, with other demands on their time. Their attendance at this debate is much appreciated.

Since 2015, when I was elected chair of the all-party parliamentary group on HIV and AIDS, our main objective has been to draw on evidence from clinicians, patients, HIV charities and research groups concerned about the potential impact of the Health and Social Care Act 2012 on HIV treatment in England. In December 2015, therefore, we started to collect written evidence so that we could investigate whether such concerns were based on reality.

Our inquiry took about a year to conclude. We heard from clinicians, local authorities, public health officials, people living with HIV, and the charity sector. We took both written and oral evidence. After a year of gathering evidence, it is fair to say that we concluded that fragmentation has occurred, creating a degree of uncertainty and presenting opportunities for aspects of HIV care to fall through the gaps between the commissioning bodies. I will outline that later.

The purpose of our report, “The HIV puzzle: Piecing together HIV care since the Health and Social Care Act”, was not to turn back the clock, but to reach out to the sector for evidence and recommendations so that we may make tangible improvements to the commissioning of HIV services. We need to work together to make such changes to ensure that people continue to maximise the benefits of the world-class treatment and clinical care service available in the UK.

I emphasise that the majority of the report recommendations focus on the need for clarity and accountability in all parts of the HIV care pathway, because the lack of clarity in the 2012 Act is what came into sharp focus. It was exemplified by the debate surrounding the provision of PrEP—pre-exposure prophylaxis—and the uncertain future of HIV support services. I and my APPG colleagues who advocate central funding for PrEP welcome NHS England’s announcement of a new PrEP trial to reach 10,000 people.

Our report concluded that the Health and Social Care Act increased fragmentation to many aspects of the care pathway, from prevention to long-term condition management. For example, fragmentation has created risks for HIV support services. The separation of sexual health and HIV is another example. There are new potential barriers to testing and prevention. Most importantly, there is confusion over the commissioning of new prevention techniques. I will highlight some of our key findings and offer suggestions as to how the APPG believes the report’s recommendations can help address them.

HIV support services—non-clinical services—have long been considered a vital part of the care pathway for people living with HIV. The British HIV Association, BHIVA, which is accredited by the National Institute for Health and Care Excellence, provides official guidance on HIV treatment and care. BHIVA states that the following are necessary for effective long-term condition management: peer support; support from other trained professionals; and information about HIV treatment, healthy living with HIV, diet and lifestyle, and optimisation of general health issues. People living with HIV also need support to access general health services, financial advice, and housing and employment support.

That view is endorsed by NHS England:

“The effectiveness of specialised HIV services depends on other elements of the HIV care pathway being in place and effectively coordinated”,

Those elements include:

“Third sector HIV care and support services for treatment adherence, peer support and self management…Social care, mental health and community services for rehabilitation, personal care or housing”.

Not everyone living with HIV requires support, and most will only need to use those services periodically, such as when they are newly diagnosed, experiencing employment issues, pregnant or considering disclosing their status to others, and if they are experiencing discrimination. The UK stigma survey identified that 28% of people diagnosed within the previous 12 months reported suicidal thoughts. Sadly, the suicide rate for HIV-positive men in the first year after diagnosis is more than five times higher than for men in the general population.

Similarly, while the side effects of treatment have improved in recent years, many people still have real difficulty in managing them, especially when starting medication or transferring regimens. People who are long-term diagnosed may experience ongoing and irreversible side effects of older HIV treatments, such as neuropathy and lipodystrophy. Most recently, there is emerging evidence on diabetes.

Support services in those instances not only ensure that people have access to a trained professional or volunteer at the point of crisis, but reduce the pressure on healthcare professionals. The National AIDS Trust reported that 50% of attendees at expert patient groups subsequently reported fewer GP visits. For an investment of £400 per attendee, the average net saving to the NHS for each patient with a long-term condition was £1,800. In addition, Positively UK reports that 88% of people reported that peer support has helped them to adhere better to their treatment plans.

Unfortunately, however, we have heard from the National AIDS Trust and other local support organisations that HIV support services are vulnerable under the 2012 Act, because commissioning responsibility has not been clearly defined. Therefore, the clearly mandated service provision has instead taken priority, in particular where there have been reductions to public health grants for local authorities. Last year, for example, HIV services in Berkshire and Oxfordshire were reduced by more than £100,000. In Berkshire, that equates to a loss of a third of the funding, which will directly affect 300 people living with HIV in Slough and Bracknell.

In Public Health England’s guidance to commissioners, “Making it work”, HIV support services are the only part of the care pathway left “to be determined locally”. That means that either the clinical commissioning group or the local authority can provide such services, but in a number of cases it appears that no one is commissioning services such as community-based HIV clinical nurse specialists.

The value of support services in other disease areas is well recognised. CCGs already commission cancer care, peer support for mental health services and the DESMOND —diabetes education and self-management for ongoing and newly diagnosed—programme for diabetes. The APPG has therefore recommended that the responsibility for providing HIV support services is met by NHS England and CCGs as part of the patient care pathway provided for long-term condition management.

Local authorities have a responsibility to provide public health and social care services, but the ambiguity in the 2012 Act and reduced funding mean that the responsibility has been deprioritised. Support services sit comfortably within the mandate that CCGs and NHS England already have to provide HIV treatment and care. Importantly, what we are asking is that the Department of Health reiterate the need for a mandated whole-treatment plan, from start to finish.

My hon. Friend is making some good points, and I commend him for bringing forward this important debate. Does he agree that one of the fundamental challenges thrown up by the Health and Social Care Act 2012 is the fragmentation of services? As a clinician, it is strange to me—I made this point when I was on the Health Committee—that sexual health services are now commissioned by local authorities and a lot of HIV diagnoses are first discovered by contact with sexual health services.

My hon. Friend makes a good point. I will go on to identify what is almost a lottery or a roulette, where people can access testing only if the parts of the health service or social care services that they come into contact with know what to do. I will also comment on the problem that some services—particularly GP services—feel that they are under so much pressure that they do not always know how to refer people for testing. One of the implications of the rationalisation of genito-urinary medicine clinics—GUM clinics—is that people risk falling through the cracks. My hon. Friend makes a good point that because services are provided in a number of places by a number of parts of the health service and it is not clear who is responsible for doing what, there is a great danger that people will think, “Someone else is doing it,” or, “Someone else is paying for it,” and we end up with no one doing it or no one having the funds to do it.

Civil society groups have highlighted that, under the Health and Social Care Act, some HIV services have been separated from sexual health services, which seems to have had the unintended consequence of creating different commissioning responsibilities for different aspects of caring for people living with HIV. HIV clinical services are commissioned by NHS England. HIV clinics traditionally sit in or next to sexual health or GUM clinics. That is the logical place for them to be; it helps with referrals and the continuation of care. Most HIV diagnoses are picked up during routine sexual health check-ups.

For example, the team at the Marlborough clinic at the Royal Free hospital, which serves my constituency, offer HIV testing and treatment alongside sexual health advice, testing and treatment for sexually transmitted infections, and contraception services. Where an HIV-positive diagnosis is made, staff can quickly link the newly diagnosed person into care at the adjacent Ian Charleson day centre, almost by walking them from one part of the building to the next, to ensure that there is continuation of care and no gap between someone being diagnosed and referred. In every part of the health service, whatever the illness or condition, if there is a gap between diagnosis and referral to a specialist service, some patients simply do not turn up. The collocation of services improves the continuation of care. The threatened merging of GUM clinics, which might take them away from HIV clinics, is therefore a cause for concern. I fear that it will make fragmentation worse.

Although local authorities are entirely responsible for providing sexual health services, they are not responsible for the entire HIV care pathway. That has resulted in sexual health services being put out to tender without a plan for the HIV service. That disruption of care presents a real problem for keeping track of patients and ensuring that they remain in the care pathway.

One of the other practical problems that was not thought through very well in the run-up to 2012 is communication between services, which my hon. Friend rightly mentioned. IT systems in the NHS often do not talk to one another very well, and they certainly do not communicate well with local authority databases or those of private sector providers, which may store information about the same person. That is at the core of the problem, and I wonder whether he might look at that issue when he makes recommendations to the Minister in the future.

My hon. Friend makes a good point. The APPG is currently considering an informal report about the future of social care. Because HIV is no longer a death sentence but a manageable condition, people are living to ages by which they expected to be dead, or by which the health service expected them to be dead. We have early indications that the social care sector simply is not geared up for handling admissions or placements of HIV-positive people into care homes and nursing homes. Some care workers are simply uneducated about how to provide support. My hon. Friend is right: as people are moved into private placements, whether they are funded by the local authority or self-funded, we will have the problem of a lack of joined-up support—not just in IT, but between social care, which is a local authority responsibility, and care for health conditions, which is the responsibility of HIV clinics with NHS support. He makes a very good point.

The disruption caused by dislocating HIV and sexual health clinics presents a real problem in keeping track of patients. As I said, collocation ensures that patients stay in the care pathway. Integrated HIV and sexual health services support young people living with HIV as they transition from paediatric care into adult services. Navigating adult HIV services for the first time can be challenging for young people. Including those services alongside sexual health services ensures that they have a one-stop shop for their HIV care and other tools for ensuring good sexual health.

The reality is that, in many cases, sexual health has become fragmented from HIV. Sexual health is the more profitable aspect of tenders, so some providers have purchased only the sexual health service, leaving no provision for HIV. In oral evidence to the APPG last year, the British Association for Sexual Health and HIV—BASHH—said that it believed that that had been a genuine oversight in the tendering process. Its president said:

“I don’t think the connection of what would happen if, particularly in a small service, the sexual health element of the tender was won by another provider. I don’t think anybody thought what would happen to the HIV service that was there. I think they thought it would just continue to be provided…and of course that may well be the case if it’s a large HIV unit, but in many cases it isn’t and it’s financially not viable, and that’s where the problem lies”.

Others report that when sexual health tenders were purchased without the HIV service, HIV clinics were left understaffed and with little certainty about the commissioning of the service. That means that people living with HIV have been required to access services elsewhere, which has led to small but significant numbers being lost to care. In its written evidence to the APPG’s inquiry, BASHH also noted:

“In a sexual health service that went out to tender a few years ago the contract was awarded to a community NHS provider. The outreach HIV clinic that had been well established was not sustainable and the service was discontinued. The majority of the service users transferred their care to other HIV providers some miles away but 9% were presumed to have disengaged in care.”

With that in mind, the APPG’s report, “The HIV puzzle”, recommends co-commissioning of HIV and sexual health services by local authorities and NHS England. Those two commissioning bodies should work collaboratively to ensure that a service assessment is in place so that the new provider, whoever it is, has a responsibility to ensure that the HIV service is maintained and not lost. The Department of Health needs to ensure that there is mandatory guidance for sexual health service bidders to undertake risk assessments and produce action plans detailing how the HIV treatment service will be transitioned and implemented.

The separation of HIV clinics from sexual health clinics is an unintended consequence of the Health and Social Care Act that needs to be addressed. The split of responsibility for different aspects of HIV care between local authorities and NHS England is leading to confusion in commissioning, and as I mentioned, early indications are that a small but significant proportion of HIV patients have fallen out of the care pathway as a result. Previously, sexual health services were all commissioned by primary care trusts and the separation of HIV services from sexual health services was unheard of.

The inquiry also identified that there remains no whole service specification for HIV and sexual health, which we believe is causing health professionals to deprioritise the service. The service specifications that do exist relate to either sexual health or HIV services through “Integrated sexual health services: national service specification” and the NHS England service specification for adult HIV services, and it is the same for paediatric HIV. Those guidelines are useful, but what is really lacking is a comprehensive service specification for HIV and sexual health that encompasses all aspects of the HIV care pathway.

That is why we recommended that the Government develop a whole service specification for HIV and sexual health, bringing together the various existing strands of clinical guidance to ensure clear and consistent advice is available to all local authorities, CCGs and NHS England. A clear service specification for HIV and sexual health would mean that there is a one-stop shop for local authorities or CCGs, which would help to remove the sense of fragmentation experienced by both patients and health professionals.

We recognise that public health is a devolved issue, but the Secretary of State must ensure that local authorities have enough guidance to ensure that there is a minimum service requirement that they must provide. At the moment, the 2012 Act does not provide enough clarity or accountability to any one commissioning body. The nature of HIV as an infectious disease means that HIV services do not start at the point of diagnosis.

Let me turn to testing and prevention, which are a critical part of encouraging safe sex. The APPG is extremely pleased with the Government’s recent announcement that relationships and sexuality education will be made compulsory in all secondary schools. Properly informed and sensitively taught, that will go a long way to ensuring that young people are able to make informed decisions about safe sex and preventing the transmission of sexually transmitted infections and HIV.

None the less, testing and prevention are subject to similar fragmentation of commissioning responsibility, so confusion over commissioning responsibilities remains. As an example, HIV testing can be paid for by any of three commissioning arms—local authorities, NHS England and CCGs—depending on the setting and context in which the test is offered. HIV testing—including community outreach—for most-affected groups and routine population screening in areas of high prevalence is the responsibility of local authorities. HIV testing clinically indicated in a hospital—and termination of pregnancy services—is paid for by CCGs. Testing and treatment for STIs, including HIV testing, provided in general practice when clinically indicated or requested by individual patients, is covered by NHS England as an essential service under the GP contract. Different settings, different funding, total confusion.

In short, if someone is offered an HIV test by a hospital doctor because they arrive in A&E with shingles, it is paid for by the CCG. If they are offered the same test for the same reason by their GP, it is paid for by the NHS primary services contract. If they are offered a test by the same GP simply because they live in an area of high prevalence, as NICE recommends, it is paid for by local authority.

The evidence for prevention and early diagnosis is overwhelming. People living with HIV can expect a near-normal lifespan if they are diagnosed early, but people diagnosed late continue to have a tenfold increased risk of death in the year following diagnosis. NICE also estimates that the costs of HIV care remain 50% higher for each year after diagnosis if the diagnosis is late. Likewise, preventing onward transmission is crucial not only for individual and public health but in terms of the sizeable lifetime costs of treatment. In 2011, PHE estimated that each infection prevented would save between £280,000 and £360,000 in lifetime treatment costs. NICE estimates that, if national testing guidance is implemented fully, 3,500 cases of onward transmission could be prevented in the next five years, saving the NHS more than £18 million a year in treatment costs.

I mentioned that GPs say they are under time pressure, and for a number of health issues that is widely reported as a barrier to proper intervention. The availability of education for GPs on offering HIV tests remains a problem. GPs feel they do not have enough information about the most appropriate time at which to intervene on HIV testing. As the Royal College of General Practitioners notes,

“There is...the issue of effective implementation—including training and support for practices to adopt these schemes...GPs and our teams are already under immense resource and workforce pressures making it incredibly difficult to implement any new programme”.

Many in primary care will therefore refer patients to GUM services for testing. However, that has the potential to entrench existing inequalities in late diagnosis rates, given that high-risk communities—particularly black African communities—are far less likely to access sexual health clinics and much more likely to access primary care.

Although healthcare professionals’ knowledge of when to offer an HIV test is not directly related to the Health and Social Care Act, the expectations from patients and the NHS England to mandate commission testing based on clinical indicators mean that educating healthcare professionals on the subject in line with NICE public health guidance must be a priority. The APPG has also called for protection of local authority public health grants from further funding reductions, in line with the Government’s commitment to ring-fencing the NHS budget. I would be grateful if the Minister could outline what plans she has to ensure that public health investment is not lost under further changes to local authority funding.

Finally, arguments over commissioning responsibilities have led to a stalemate on the introduction of innovation in HIV prevention. In 2015, studies from the UK, France and the US reported that, when taken regularly, PrEP can reduce the risk of HIV transmission by up to 86%. As the National AIDS Trust notes:

“PrEP is exciting, new, and currently, unique. It is not a vaccine, although it has a similar impact. We can draw comparisons to statins, in terms of preventing illness, or contraception, in terms of preventing unwanted consequences of sex. But actually, there is nothing quite like it. It is the definition of healthcare innovation.”

I do not wish to repeat the arguments made for and against the centralised commissioning of PrEP, but it does serve as an important case study in highlighting how the fragmentation outlined already risks HIV services that are focused on both lifelong condition management and preventing onward transmission.

As I mentioned at the beginning of my comments, I am enormously grateful to the Minister and NHS England for the announcement of an expanded clinical trial phase, including at least 10,000 participants, which will be launched early in 2017-18. I hope she will be able to update us on that trial in her response. I thank everyone who participated in the inquiry, particularly those who travelled across the country to attend our oral evidence sessions, and all the members of the APPG who took enormous time out of their diaries to support the inquiry.

It is a pleasure, as always, to serve under your chairmanship, Mrs Main. It was a particular pleasure to hear the hon. Member for Finchley and Golders Green (Mike Freer) set the scene for us on a subject that is close to his heart and one that he has become a champion for in this House. I congratulate him on that. I have always been here to support him in his endeavours, and I am pleased to do likewise again.

When we think of HIV, as we are doing in this debate on the report, our thoughts automatically go to African nations. They do in my case, and Swaziland in particular, as my parliamentary aide visits and supports an orphanage there. One in every two people there has AIDS, so there is naturally a massive need for care and support of orphans. My heart has long been touched by the needs of the people in that country who have been ravaged by the spread of AIDS, and by the work of the World Health Organisation and other charities such as Teen Challenge and Elim Missions, which are active in my constituency.

However, this debate is about the report, which makes it clear that this is an issue much closer to home as well as one in Africa. We can relate it to our own constituencies. I understand that health is devolved to Northern Ireland—at least it is now; we will see how these talks go. The Minister might be the person making the decisions. We will have to see what happens in relation to that. With great respect, I hope she will not be making those decisions; I hope we will be making them back home, but that is by the by.

In Northern Ireland in 2015 there were 103 new diagnoses of HIV, bringing the total to almost three times what it was in 2006. Some of these figures are shocking and worrying. That is the highest number of HIV diagnoses to ever be recorded in a single year in Northern Ireland. From 2000 to 2014, a total of 557,000 HIV tests were carried out in Northern Ireland.

In Northern Ireland a total of 126 people diagnosed with HIV have died. That includes AIDS and non-AIDS-related deaths. Data obtained from the Public Health Agency showed that 114 pregnancies were affected by HIV from 2005 to 2016. Encouragingly—there is always a good message to be told—the pregnancies were managed to prevent the infection being transmitted from mother to child. That is certainly a bonus and highlights the importance of knowing about infection and managing the birth of babies correctly. We have come forward with medicine and medication over the years in an innovative and very effective way.

In 2015, there were some 6,095 new cases and 88,769 people being treated for HIV across the UK. This is not an African infection; it is a problem in the UK that we must address. In setting the scene for us, the hon. Member for Finchley and Golders Green focused attention on where it should be in this debate: where we are in the United Kingdom. Some 101,200 people were estimated to be living with HIV in the UK by the end of 2015.

As with many illnesses, many people are living with the disease without knowing it. I would like to hear the Minister’s thoughts on how we can reach people out there who are carriers and perhaps do not know it. The clear fact is that, if people are not diagnosed, there is a much greater danger of them unwittingly spreading the infection.

It is estimated that 87% of people are diagnosed; 96% of those diagnosed are accessing treatment; and 94% of those accessing treatment are virally suppressed or “undetectable”—the virus will not show up on tests; it is unable to be transmitted to others. Those are some of the facts. That means that around 13% are undiagnosed and unaware of their infection—they are not able to access care to protect their wellbeing and prevent the onward transmission of HIV to others.

It has been estimated that each new infection costs the NHS between £250,000 and £360,000 in direct lifetime treatment costs. That is something we need to address, and the Minister must at least consider it. The number of new diagnoses in 2015 was slightly lower than in 2014, but new infections have remained roughly static since 2010. The fact that there are new infections each year is something we cannot ignore and needs to be addressed. I am keen to know the Minister’s thoughts on the best way of doing that.

Some 39% of people are diagnosed late, which has a potential impact on their immediate health and therefore the cost of treatment at the point of diagnosis and beyond. The fact that people are diagnosed late indicates that there was a possibility of diagnosis earlier. If that is the case and it has not been done, why? There must be a proactive approach to encourage screening and to reinforce education and learning about the prevention and spread of HIV and sexual health in general.

I tabled a question some time ago, to which the Minister responded, on the increase in sexual infection among those in the 50-to-70 age bracket. The figures indicate a rise in HIV infection among that group as well. I ask this question because it is important to do so. When people get to a certain age in life, they may not be involved in those activities as much as they may have been in the past, but there has been a rise in sexual diseases in that age bracket. I know the Minister responded to that question last year, but I would like to hear an update on her thoughts.

Some of the recommendations in the 2016 report from the all-party parliamentary group on HIV and AIDS on the impact of the Health and Social Care Act on HIV services bear highlighting. The first one that I want to mention states:

“While public health has been devolved, the Secretary of State must ensure that local authorities have enough guidance to ensure there is a minimum service requirement, which they must provide.”

The hon. Gentleman mentioned that in his introduction and clearly outlined the issue. With respect, at the moment the Act is not providing enough clarity or accountability, and it is the Department of Health’s responsibility to ensure that it does.

I look to the Minister, as I always do—she is a very responsive Minister—and ask what co-operation there has been with the regional devolved Assembly in Northern Ireland and the Health Minister there. What plans are in place for such engagement, involving the Secretary of State or Minister of State for Northern Ireland, should we return to direct rule? We cannot afford for health to suffer due to the reluctance of Sinn Féin to enter into government with the party with the largest mandate—the Democratic Unionist party. It is the responsibility of Ministers in this place to step in and step up if necessary and ensure that the people of Northern Ireland have the right strategies in place.

I was quite encouraged by the Library briefing on this debate, which has been extremely helpful. It mentions the pre-exposure prophylaxis drug Truvada, to which the hon. Gentleman referred. There are some excellent medications today, and that is one of them. It is a brilliant, new, innovative drug that can make a difference. It can save lives, stop or at least control HIV infection and give a longer life. We must welcome some of the things that are happening out there and that the NHS is providing, because it is tremendous news.

Lastly, it is clear that the Department of Health needs to ensure there is mandatory guidance for sexual health service bidders to undertake risk assessments and produce action plans, detailing how the HIV treatment service will be transitioned and implemented. We need to have that in place. It is not enough to put a couple of adverts in the media. Although that is good and should be done, it is not enough. We must have a strategy to deal with the prevention of this disease. We must also remember that it is not something that affects only one nation; it affects us all in this nation of the United Kingdom of Great Britain and Northern Ireland, and we must deal with it effectively. I look to the Minister for an indication of how she intends that to be done.

I congratulate the hon. Member for Finchley and Golders Green (Mike Freer) on securing this debate, on his all-party group’s excellent report and, indeed, on all the work he does on HIV and AIDS. I draw attention to my entry in the Register of Members’ Financial Interests and declare an interest: I am a trustee of the Terrence Higgins Trust.

The hon. Member for Finchley and Golders Green is absolutely right, as is his report, on the impact of the Health and Social Care Act 2012 passed in the previous Parliament. I am sure the Minister has read not only his APPG’s report but the Health Committee report that we published last year on public health in general and the impact of that 2012 legislation on the delivery of public health, and particularly the delivery of sexual health and HIV services across the country.

The hon. Gentleman is right that, in our report, we identified a number of problems and challenges with the new landscape and commissioning structure. We heard from people up and down the country in evidence—HIV/AIDS organisations, those who work in sexual health, consultants and virtually everyone else—that the area that has been hit most negatively by the Health and Social Care Act and the changes in commissioning arrangements are HIV services and sexual health services more generally. We all have our own ideas of why that might be the case. Although the jury is still out about the decision to pass the responsibility for public health to local authorities, there were concerns expressed at the time of the Health and Social Care Act—some of us warned the then Health Secretary, Andrew Lansley—about the potential impact of giving local authorities the responsibility for HIV support and other sexual health services, but I am afraid those concerns were not listened to. I hope the Minister will explain to hon. Members and to the country at large what monitoring the Government have been doing on the impact of the Act on services and what measures or action the Government will take as a result of anything they find.

I agree with the right hon. Gentleman. Does he agree that one challenge is the fact that local authorities are now commissioning the provision of health services in complete isolation from many of the other HIV and associated services? That is very different from our general understanding of public health at the core of the Act—it is a fault.

I completely agree with that point. The different commissioning responsibilities for different bits of sexual health and HIV and AIDS are all over the place. On top of that, although the Government can, with some justification, claim to have protected NHS spending in cash terms if not in real terms, they cannot claim to have done that when it comes to public health, which has taken significant cuts and will continue to take significant cuts over the next few years. Of course, those cuts are being imposed on local government. As the hon. Gentleman and other hon. Members know, local government faces huge financial challenges across the piece. There is also the threat of the withdrawal of the ring fence on public health funding in the next two or three years. In our report we made it clear that we thought that was a risky move indeed.

I do not want to repeat a lot of what was said by the hon. Member for Finchley and Golders Green, who made a comprehensive and excellent speech, but I hope the Minister will explain to us what monitoring the Government are doing on the impact. What will they do in response both to the concerns raised and the recommendations of the all-party group report and our Select Committee report to address the problems? We have known about them for some time—our report is now more than a year old.

The news about PrEP is very welcome, but will the Minster clarify the timing of the commencement of the trial? While we are on the subject, another potentially welcome development is the big fall-off in HIV presentations or positive tests at some of the London clinics in the past few months, which some people suggest may be to do with the availability of PrEP. Can the Minister tell us whether she has made an assessment as to whether that is the case, in which case it is a promising development indeed?

Finally, one of the things that concerns me is the plight of older people living with HIV and AIDS. Around a third of the people in Britain now living with HIV and AIDS are over 50. About 60% of them live at or below the poverty line. When many of them were originally diagnosed, they did not expect to have a long life expectancy, but they are still here thanks to the fantastic treatment and care that has been invented and developed, which has not only helped to keep people alive but enabled them to lead lives of reasonable quality. Back when they were diagnosed, they may have been less cautious about spending their money to get by at that time, and now they find themselves hopefully with many years stretching ahead and no more means at their disposal, so there is a particular challenge when it comes to older people living with HIV and AIDS. That will require the Department of Health to work more closely with the Department for Work and Pensions. Some of the people that my charity—the Terrence Higgins Trust—deals with face problems when it comes to benefits and benefits sanctions. Those sorts of things add extra pressure and misery to the challenges that people living with HIV already face.

I apologise for arriving late and missing the start of the debate, Mrs Main, but I was waiting to speak in the Prime Minister’s statement. It is a pleasure to serve under your chairmanship again. I long for the day when I can get called as quickly as my right hon. Friend the Member for Exeter (Mr Bradshaw), who gets called with such speed and alacrity.

I long for that day as well, but that is in the lap of the electorate. I also thank the hon. Member for Finchley and Golders Green (Mike Freer). He heads up some incredible work by the all-party group, which has provided remarkable and concise information that is usable not only within the sector, but by a great number of people, to advocate for the challenges of people living with HIV and AIDS and to help to explain the broader issues people face. The reports are read by a great many individuals, and not only by experts in the subject, which is a credit to him. His wide-ranging speech—the last three quarters that I caught—was exceptional, and I am grateful to have been here for it.

I represent the city of Brighton and Hove, which has more than four times the national average HIV contraction rates and people living with HIV. That places an additional onus on me to give voice to both the sector and the individuals who live with this long-term condition. I am a representative for that city and for the gay community. When I was on the board of Pride, I spent a lot of time trying to understand the fabric of the support services going to people living with HIV, and I have done so with even more enthusiasm and dedication since being elected as an MP.

I am proud that we have incredible preventive work in Brighton and Hove. THT, Stonewall and local groups, co-ordinated through the LGBT Forum, have done remarkable work on prevention. It is a sadness that they do not have all of the tools that they call for, including PrEP, at their disposal. I know that the issue has been aired by other Members today, so I will not go into any more detail on that, but the grassroots and the people working on the frontline in Brighton and Hove are absolutely enthusiastically calling for that.

I, too, wish to add my thanks to the hon. Member for Finchley and Golders Green (Mike Freer). Does my hon. Friend agree that having such a confusing and complex mix of commissioners and authors of standards for prescribing does not help to establish the consistent commissioning of drugs such as PrEP, which he has mentioned and which would help so many people not only in his own constituency, but in Bristol West?

Bristol and Brighton share many of the same characteristics in terms of demography and the numbers of people living with the long-term condition of HIV/AIDS. I agree with my hon. Friend wholeheartedly. The hon. Member for Finchley and Golders Green made the point very well about the split that was created in the Health and Social Care Act. It is having an impact on communities and I hope Ministers will finally realise that that needs to be prioritised.

In the work I have been doing with the people who deliver frontline services, I have learnt that the people who live with HIV/AIDS often have complex needs. The landscape for provision is also complex and moves from prevention to treatment. As my right hon. Friend the Member for Exeter mentioned, people are living into old age with HIV—that is not entirely new, but it is a fairly recent development. We should celebrate the fact that people now live into old age with HIV, but it presents us and our health service with very complex challenges.

I too have met people living into their 70s and 80s with HIV, who, when they were first diagnosed pre-1996, were given just weeks to live. There is an additional challenge for such people, as hinted at by my right hon. Friend. Many of those people are not only vulnerable because of the comorbidities and complex health challenges that they may have, both physical and emotional, but many of them spent all of their money when they thought they had a very short time to live, so they are additionally vulnerable because of their financial position. That means those individuals need the holistic care that they deserve.

The hon. Member for Finchley and Golders Green spoke well about the split created by the Health and Social Care Act 2012. I have seen its direct impact on support for people living with HIV. Some people are failing to get the comprehensive care that they need. That is leading, first, to individuals with complex needs not getting the comprehensive care they need, and, secondly, to providers of comprehensive care not getting the funding they need to provide the services. That is causing a terrible ruction in the provider landscape for HIV. Specifically with regard to Brighton and Hove, I am referring to the Sussex Beacon—I shall talk more about that in case the Minister is not aware of its fantastic work.

First, it is important to describe the general health landscape in the city of Brighton and Hove, which is in crisis. We have a hospital, a clinical commissioning group and an ambulance trust in special measures, as well as patient transport services whose privatisation was botched, and which were then renationalised, all within six months. On top of it all seven GP surgeries have closed in the past 12 months. The service is comprehensively in crisis. However, there is one jewel in the crown—the Sussex Beacon, which was established as a hospice in 1992, to provide end-of-life care for people who were dying because of HIV and AIDS. It has flourished and evolved as the needs of the client group have changed and evolved over time. It is a remarkable organisation, providing preventive, outpatient and inpatient services, and more than 2,000 bed nights a year.

Last year the Care Quality Commission said that the Sussex Beacon is outstanding. It is one of the true beacons of health in the community, and I am proud that it exists to provide comprehensive, holistic and tailored care for individuals living with HIV. It is incredibly important to the community. Because of the split, however, no one agency is taking overall responsibility for funding the Sussex Beacon any more—not the local authority, and not any of the funding agencies designated to do so by central Government. As a result, its statutory funding has fallen by £400,000 a year. That funding gap is bringing an extraordinary organisation to its knees.

In Brighton and Hove politics there is a rainbow coalition. The three MPs are each from different parties, but last year we united in writing, along with the leader of the council, to the Health Secretary, to point out how extraordinary the work of the Sussex Beacon is, and what the dangers are. We pointed out what would happen if all its client group—people with extremely complex needs who were used to and are deserving of specialist care for the special challenges they face—were to be transferred from somewhere rated outstanding to somewhere in special measures, such as a hospital struggling to cope with the patients it has at the moment. Before the general election, the Health Secretary took time to come to Brighton and visit the Sussex Beacon for a photoshoot, as did the Prime Minister when she was Home Secretary on another occasion. Sadly, neither had time to respond to the letter about the dangers that the service will face in future. It was passed on to another agency in the Department of Health for a response.

Perhaps people felt that we were crying wolf, but we were not. The trustees of the Sussex Beacon have issued a warning that they will start to shut services from June this year unless the funding gap is closed. Staff have been put on notice of redundancy. We are in the last chance saloon for that fantastic organisation, which is celebrated beyond Brighton for the services it provides. I urge Ministers to consider the specific challenges it faces. The Minister will know what an achievement it is in today’s health environment to get an outstanding rating for something so complex, meeting such complex needs. Because of the nature of the debate, she will know that the people who use the services count on them in a heartfelt, emotional and dependent way. It is an extraordinary service and I urge her to look directly at the challenge and see what the Government can do. Once the service is lost it will be gone forever, and will not be coming back.

I labour the point for two reasons: because I am a Member of Parliament for the area that the Sussex Beacon serves and one of its patrons, but also because it speaks to the challenges that comprehensive providers face in an environment in which funding has become very specialised and very narrow. Comprehensive providers are struggling to find their feet in the new environment. What is happening to the Sussex Beacon is relevant to the broader challenges faced by the sector, in the broader health environment.

It is a pleasure to serve under your chairmanship, Mrs Main, and to take part in today’s debate. I am grateful to the hon. Member for Finchley and Golders Green (Mike Freer) for securing the debate, and for his detailed and informative speech, as well as for the work of the all-party group on HIV and AIDS in producing an excellent report, “The HIV puzzle”. The report notes, on the basis of evidence from charities, civil society groups and the pharmaceutical industry, significant upheaval to HIV and sexual health services since the Health and Social Care Act 2012 was implemented.

The findings of the report are very worrying. A joined up, multi-sector approach to support and care for those at risk of or living with HIV is crucial to its prevention. The UK Government should reflect seriously on how they can improve HIV services in the light of that body of evidence. The report is concerned with HIV services in England, but its findings will be of interest throughout the UK. Communicable diseases do not, after all, recognise administrative or national borders. The report recognises:

“In Scotland sexual health sits under Blood Borne Viruses in the health system, which Dr Gordon Scott argues makes it easier to set priorities.”

In that spirit, and given that the issue is devolved, I hope that the comments of a Scottish Member about HIV in Scotland will also be of interest to Members from other parts of the UK.

There were 6,095 new diagnoses of HIV across the UK in 2015, and 300 of those were in Scotland. The latest figures for NHS Lothian, which covers the West Lothian part of my constituency, tell us that there are 1,589 people diagnosed and living with HIV, and that 70 of those were diagnosed in the past year. At the other side of the country, Glasgow has experienced its biggest rise in HIV infection for three decades. The issue will affect every community in the country. We all have our challenges, especially when we consider that it is estimated that about 13% of people may be undiagnosed, with all the consequent risks of onward transmission, as well as the impact on those people of being unable to get access to care and treatment.

Lifetime treatment costs the NHS between £280,000 and £360,000 per patient—a not insignificant amount. Prevention of HIV infection remains a priority for the Scottish Government. There is no room for complacency on communicable diseases such as HIV. We continue to provide funding to NHS boards for HIV prevention, as well as supporting organisations such as HIV Scotland, with £270,000 in funding this year. There is of course no one-size-fits-all approach to HIV prevention. That is why in Scotland we are providing Waverley Care with £45,000 in funding this year for its HIV prevention and support work with African communities.

A joined-up approach to HIV care is vital to ensuring that infected people can get the care they need to live life as independently as possible. The Scottish Government’s sexual health and blood-borne virus framework 2015 to 2020 is continuing to build on achievements made under the original framework document of 2011. The HIV Testing Kits and Services Revocation (Scotland) Regulations 2014 lifted the ban on the sale of instant-result testing kits in Scotland. In the light of that change, and following leadership on the issue by HIV Scotland, a subgroup of the executive leads group published a questions and good practice document on instant-result self-testing in March 2014. The good practice document was the first of its kind in the world and has since been recognised internationally as an example of good practice by the World Health Organisation.

All NHS boards in Scotland have protocols in place in relation to HIV post-exposure prophylaxis—PrEP—for sexual and non-sexual exposures. The framework makes clear the importance of a multi-agency approach to sexual health and blood-borne viruses. Truly delivering on the framework outcomes in the long term will require the involvement of patients and service users, NHS boards, local authorities, the third sector, academics, the media and, indeed, the general public. The integration of health and social care in Scotland is one of the most significant reforms since the establishment of the NHS. We are the only UK nation to have legislated to put NHS boards and local authorities under statutory duties to work together. That is helping to tackle priorities in the framework to work towards as joined-up an approach as possible to caring for people with long-term conditions and disabilities, such as HIV.

Evidence generated in late 2014 and early 2015 indicates that the HIV infection is being transmitted among a small population of highly chaotic, vulnerable and often homeless people who inject drugs. These transmissions reinforce the importance of prevention work with such populations. The Scottish Government are working with health boards, schools and the police service to ensure that vulnerable groups can get the right support to prevent and treat infection. The framework update includes commitments on development of care services with local authorities; tackling social stigma through education; encouraging HIV testing to be regarded as routine; and NHS boards and partners offering testing to vulnerable groups using innovative approaches such as delivering testing in the communities themselves.

The Scottish Government are also considering the recommendations of an independent review of PrEP. The European Medicines Agency has granted a licence for Truvada as PrEP for HIV in adults at high risk. The Scottish Government’s chief pharmaceutical officer has written to its manufacturer to ask it to make a submission to the Scottish Medicines Consortium. The Scottish Government’s position is that all medicines must be licensed before they can be made routinely available on the NHS, but we recognise that some people are already buying PrEP drugs privately in Scotland. It is important that people who are doing so receive appropriate advice from and are monitored by clinicians. The executive leads network for the sexual health and blood-borne virus framework is considering the findings of the PrEP short life working group, which considered a range of issues associated with the use of PrEP. I look forward to hearing about the outcomes.

In conclusion, I commend the work of the APPG and its report on this issue. There are undoubtedly lessons for us all within it.

It is a pleasure to serve under your chairmanship, Mrs Main. I thank the hon. Member for Finchley and Golders Green (Mike Freer) for his excellent chairmanship of the all-party parliamentary group on HIV and AIDS, for securing this important debate and for his comprehensive opening speech. It was a tour de force.

I also thank the other hon. Members who have contributed to the debate. I thank the hon. Members for Strangford (Jim Shannon) and for Linlithgow and East Falkirk (Martyn Day), my right hon. Friend the Member for Exeter (Mr Bradshaw) and my hon. Friends the Members for Hove (Peter Kyle) and for Bristol West (Thangam Debbonaire) for their excellent and knowledgeable speeches and interventions. They will all have given the Minister much to think about.

We have come a long way since the height of the HIV/AIDS epidemic of the 1980s, but that does not mean that we should be complacent in our approach to the disease now. Across the UK, an estimated 101,200 people were living with HIV by the end of 2015; 87% of them had a diagnosis, and 96% of those diagnosed were accessing treatment. Although they are a minority of people in the wider population, they are a significant minority that we cannot let down when it comes to their care and treatment.

The number of people receiving HIV care in 2015 in England was just over 81,000. That is a 73% increase in the number of people accessing HIV care since 2006. In part, that is welcome, as it means that more people are accessing care that can improve their lives, but it also provides us with reasons to ensure the future quality of care provided, and that is the crux of why we are here today to debate this issue.

As the APPG highlighted, it is understood that since the passing and implementation of the Health and Social Care Act 2012, there have been growing complications with the commissioning and provision of HIV services across the healthcare system. In the rest of my contribution, I will touch on the Health and Social Care Act’s impact on HIV services, but I will also expand into other areas, such as the cuts to public health budgets and the worrying trend of decommissioning of HIV services, and finally I will touch on issues regarding PrEP.

Since the passing of the Health and Social Care Act, there has been a significant fragmentation of our NHS and wider health services. During the passage of the Act, Opposition Members felt that it was an unnecessary top-down reorganisation. The case of HIV services proves exactly how that fragmentation is causing consequences for the future of vital services. The creation of CCGs and the devolution of public health to local authorities have fragmented HIV services across various bodies, with no coherent commissioning and oversight. Currently, services are failing to maintain the standard that patients expect. That is down to commissioning responsibility not being clearly defined under the Health and Social Care Act. Although the coalition Government argued that the Act would ensure the streamlining of services, the opposite has clearly been the case for HIV services.

I therefore want to push the Minister on what she is doing to look into the APPG’s recommendations, especially about joint commissioning for support services by NHS England and CCGs, along with co-commissioning of HIV and sexual health services by local authorities and NHS England. Another issue that the Minister must look at—I raise this repeatedly with her—is public health funding. The cuts to services further exacerbate the problems that HIV services face because of commissioning responsibilities being unclear, which is pushing services to walk away from their responsibilities.

I know that the Minister will reference the funding going into regular HIV testing and the promotion of safe sex, along with the HIV innovation fund, but the impact on funding cannot be ignored. Last week, the National AIDS Trust published a report showing that in England, there has been a 28% decrease in the expenditure between 2015-16 and 2016-17. That is on top of the cuts to HIV support services, or decommissioning of said services, in Lambeth, Southwark, Oxfordshire, Portsmouth and Bexley. Although public health budgets are only one part of the funding streams for HIV support, treatment and care, they are nevertheless an important part of the pathway, as cuts to sexual health services more broadly are detrimental to HIV care. The £200 million in-year cut and 3.9% cut year on year will only have a negative impact on the future of all sexual health services, including those for HIV. The Minister must seriously address that false economy, or risk seeing a public health crisis that could easily have been avoided.

I thank my hon. Friend for the excellent speech that she is making. I want to add my support for what she has just said, and perhaps go a bit further. Does she agree that the Minister needs to address the fact that the failure to address preventive services will only store up costs and problems further down the line, and that when there are cuts to public health grants, those services need to be ring-fenced or protected in some other way so that we are not storing up problems for the future?

I thank my hon. Friend for that helpful intervention. I agree with her absolutely. The whole point of preventive services—HIV and sexual health services are preventive—is to save money, and lives, further down the line. We regularly debate preventive measures for other health issues with the Minister in this Chamber.

There is still a question mark over the future of HIV services, not only because of the cuts that we are seeing now, but because the future of public health budgets after 2018 is not guaranteed. There are also issues with the devolution to local authorities of business rates, which will be used to fund public health spending. The Government have still not published details of how they aim to ensure that public health will continue to be prioritised when that comes into effect. I hope that the Minister will be able to offer clarity today.

PrEP is a highly effective way of protecting someone who does not have HIV from contracting it. As the UK PROUD study showed, it was 86% effective in preventing HIV transmission and, if taken correctly, it has closer to a 100% success rate. That is why it is important that this drug treatment is supported as much as possible. While the announcement on the feasibility study is welcome, questions remain that the Minister must answer. Nearly four months since the trial was announced, we are still none the wiser as to when it will begin, other than that it will begin early in the 2017-18 financial year. I welcome that in her letter to the APPG yesterday the Minister said that the trial would begin in the summer, but I hope she will offer further clarity on when we will know more. There remains an issue with the drug Truvada, which is used in PrEP. For the trial to reach the 10,000 people that it plans to, a generic version of Truvada will need to be used. I am interested to know what conversations the Minister has had with Gilead, and how co-operative it has been to ensure the success of the trial.

Finally, I want to ask the Minister about the concerns that many PROUD participants will run out of their supply of PrEP this week, and that between 350 and 4,000 individuals at the highest risk of HIV will run out of supplies. That is a matter of urgency, and the Minister must address it as a matter of priority. We cannot allow the people who take this drug treatment to be put at risk. Therefore, I hope the Minister will go away today and look at the matter immediately.

These issues are highly important to many people who live with HIV or within those communities where infection rates are more common than in others, as we heard from my hon. Friends the Members for Hove and for Bristol West. I was shocked and surprised to hear that there is four times the normal rate of those people in the community of my hon. Friend the Member for Hove. I am well aware why he is here today to speak for his constituents.

The Government’s mismanaged approach to the NHS’s structures and to wider health services is seeing services fall through the gaps and people’s lives affected, which is exacerbated by short-sighted cuts. It is important that we recognise the work that has already gone into addressing HIV in our society, but accept that we still have a long way to go. We cannot squander these opportunities, as we could see yet another public health crisis due to complacency and failure to step up and address this issue. I hope the Minister has listened carefully to all the contributions to the debate and the seriousness of it, and will go away and do the right thing by the tens of thousands of people living with HIV or at those risk of contracting it, and support them. They should not be let down.

It is a pleasure to serve under your chairmanship, Mrs Main. I congratulate my hon. Friend the Member for Finchley and Golders Green (Mike Freer) on securing this important debate, and all Members who have contributed to what has been a highly informed discussion. I welcome the opportunity to discuss the findings from the recent and interesting report “The HIV puzzle”, which was produced by the all-party parliamentary group on HIV and AIDS. I pay tribute to my hon. Friend for his work on HIV innovation, and to all the members of the APPG for the work they do to champion HIV within Parliament.

Preventing the spread of HIV and supporting those who already have the disease remains a Government priority. As colleagues present will have heard me say before, and as the shadow Minister, the hon. Member for Washington and Sunderland West (Mrs Hodgson), also said, when we look back at the HIV epidemic in this country we can be proud of our achievements so far. In particular, we have made considerable progress in recent years towards meeting the UN 90-90-90 ambitions to eliminate HIV-related mortality and transmission by 2020. We have already met two of the ambitions, with 96% of people diagnosed with HIV receiving antiretroviral treatments and 95% of those treated virally suppressed. We have made significant progress on the third goal—to reduce undiagnosed HIV so that diagnosis is over 90%. The proportion of undiagnosed cases was 13% in 2015, which means we have seen a fall of almost half, from 25%, in just five years. However, that is still too high and we need to redouble our efforts to ensure that those who are positive receive a timely diagnosis.

The right hon. Member for Exeter (Mr Bradshaw) was right that we must have robust monitoring to ensure that we understand what is happening. He identified some particularly encouraging reports from London; there were some encouraging reports during 2016 from London clinics, particularly Dean Street. Those trends are welcome. Public Health England is actively investigating the trends, and whether the reduction has also been seen in other parts of the country and in other risk groups. It will report on that when the 2016 HIV data are published later this year, and I shall be happy to notify him if he would find that helpful.

Many Members today have reported concerns about how public health funding in the future might affect the provision of HIV prevention and support services. In line with recommendation 6 in the report, we have decided, in relation to this aspect and wider public health funding, to retain the ring fence on the public health grant for a further year, until 2019, as we move towards the implementation of local business rates retention. This is a step on the way to a more locally owned system, but that will help to smooth the transition by providing certainty for the next two financial years. It means that grant conditions will continue to apply and Public Health England will have a clear assurance role in relation to grant spend. I recognise that local authority funding remains tight and that councils have tough decisions to make to ensure that vital public services remain sustainable. Returns from local authorities have identified that more than £82 million was spent on sexual health.

I thank my hon. Friend the Minister for the constructive approach that she is taking in replying to this debate, as indeed she does in all debates on health matters. Does she recognise that there are areas with very high demographic change, that some of them have high rates of people living with HIV and that the funding formula is beginning to be out of date and needs to be reviewed? There are some parts of the country that need more money than that funding formula makes available for public health purposes.

I am going to come to what we are going to do in the future. The current situation will remain in place for one year, but we have identified the public health spend. A significant proportion of the funding will be allocated to HIV testing and prevention activities. We also recognise that there are reasonable concerns about the practicalities as we move towards business rates retention, and how it will work in practice, in particular in relation to health. The fact is that the only way we are going to get the scale right is if we continue to engage closely with Members. One thing we are looking at is how we manage the move towards mandation and how we look at transparency and accountability in public health spending. We will be doing that in a very consultative way—

I am sorry to interrupt the Minister. I think she mentioned a minute ago something about protecting public health funding for two years until the change to business rates. I am so sorry, but I missed that point. Could she clarify it? Does she mean that this is a new announcement of new protections?

The public health ring fence will remain in place until 2019.

We also recognise, as recommendation 1 makes clear, that HIV support services are an important part of the overall care that people diagnosed with HIV receive to support their health and wellbeing. I have heard hon. Members’ concerns today about such services being decommissioned because of budget pressures. We are increasing our focus on supporting and improving place-based commissioning, and will work to provide the right opportunities for all commissioners and providers involved in a care pathway to work together to secure the right service response for the needs of the local population, taking into account each partner’s responsibilities.

In line with a number of the recommendations, we also need to ensure that we make the most effective and efficient use of the resources available. We are already seeing some really effective examples of that in the Public Health England HIV innovation fund, which supports voluntary sector-led projects across the country that are focusing, as my hon. Friend the Member for Finchley and Golders Green knows only too well, on HIV prevention and testing. That includes the OutREACH project in Cumbria, which is using community pharmacists to provide HIV testing in a rural area with very high rates of late HIV diagnosis, and the MESMAC project in Yorkshire, which is providing HIV awareness training and testing at a hostel housing migrants who are claiming refugee status in the UK. We are also encouraging innovations such as home testing. Our aim this year is to see 50,000 tests for HIV carried out at home. They are already starting to make a difference. The introduction of compulsory relationships and sexuality education will, as my hon. Friend says, have an important role to play in prevention.

I was very sorry to hear the comments made by the hon. Member for Hove (Peter Kyle) about the Sussex Beacon. I am sure that, given his account of the clear local need and the quality of the service, he is holding local commissioners to account for their decision making. I am afraid that my recollection is that I had responded to him on that matter, and not an arm’s-length body. I am very sorry if there has been confusion, but I am happy to continue the discussion following this debate, so that we can clear it up and ensure that we make progress on it. I would not like him to think that we do not take it very seriously indeed.

As we all know, delivering high-quality HIV services is about not just funding, but getting the commissioning right. As the report highlights, a lot of work still needs to be done to ensure that the commissioning landscape for the services supports effective collaboration and co-operation, so that we can continue to see improvements in these and other outcomes. That is exactly why Public Health England commissioned a sexual health commissioning survey, which very much supports the findings of both the Health Committee and APPG reports.

I recognise that commissioning sexual health and HIV services is complex, given the range of services and the different population needs that are covered under the broad umbrella of sexual and reproductive health and HIV. We are very alive to and are working to address the risk of fragmentation damaging the progress that we have made, so I am particularly pleased to announce that, shortly, Public Health England will launch an action plan to support commissioners and ensure that they can provide the sexual health and HIV services that their populations need.

As its first priority, Public Health England will look for ways in which to reduce the fragmentation of commissioning and address the barriers that stop effective collaboration and co-operation between commissioners. That will include encouraging the development of a model of lead integrated commissioning in each locality, including developing models for out-of-area tariffs and other issues that can slow down contracts and increase costs. PHE will also identify system leaders across the country to lead local sexual health, reproductive health and HIV commissioning in an agreed locality and form a national network of commissioning leads to promote the effective national development of commissioning.

To test out how that might work in practice, PHE will pilot local delivery models working with local authorities and CCGs to help to build on effective models of commissioning. We will announce the names of the pilot sites shortly—the work is still in the early stages of implementation—but I take this opportunity to urge any areas that are interested in working with us to get in touch with PHE and to take part in developing the work as it takes shape.

I warmly welcome what the Minister has just announced. When the pilots are up and running and have delivered results, if it is necessary to revisit some of the structural and commissioning changes that were made under the Health and Social Care Act and which caused the problems in the first place, would she be open to doing so? On the ring fence, if she is going to delay its removal by a year, she might as well have a proper review of that, given the concerns out there about the impact of removing it on public health funding and spending in general.

I think the right hon. Gentleman slightly misunderstood me on the ring fence. We have kept it because we believe that transparency and accountability measures need to be put in place, so that when local authorities move to business rates retention, their decisions can be made in an appropriately accountable way that can be scrutinised properly. We do not feel as though we have that yet, so we have moved the date back a bit. We want to do that effectively and to have proper consultation on the mandate. On his other point, I think it is a bit early in the process to start discussing that.

Given the time, let me move on to service specifications. During the debate we have heard examples of contracts for sexual health services becoming divorced from the provision of HIV services. A key recommendation from the APPG report was to create a joint service specification for sexual health and HIV services. We recognise that the existing service specification for sexual health needs strengthening, which is why it is now being updated. PHE has committed to building on existing commissioning guidance to provide more focused advice and examples of locally designed systems to support the commissioning of HIV and sexual health services.

NHS England is responsible for the service specification for HIV treatment and care, and we think that that remains a sensible division. However, the development of a new integrated service specification for sexual health services will allow us the opportunity to join up our advice to produce a more integrated offer.

I want to recognise the continuing priority of PrEP, which many colleagues mentioned, and the trial that was announced last year by PHE and NHS England. Up to £10 million has been set aside to fund the trial, which is anticipated to include at least 10,000 participants over the next three years. We expect the trial to be under way this summer. It has the potential to change the lives of thousands of people who are at risk of contracting HIV.

I asked about where the older generation featured in things, as did the right hon. Member for Exeter (Mr Bradshaw), but the Minister has not touched on that yet. If she is not able to do so now, perhaps she can come back to us in writing.

The whole point of developing a much more systematic process and having a commissioning programme that does not allow the fragmentation of services, but instead is much more integrated, is that it will take into account more ageing people living with HIV. We believe that that will deal with the issue.

The hon. Gentleman also asked how we will tackle the issue of undiagnosed people living with HIV in the community. We believe that the strategy of increasing education and introducing compulsory sex and relationships education will be part of that, as will improving our performance, testing and early diagnosis. The work being done through the innovation fund is a key plank of that. Having clear specifications in commissioning guidelines so that we have coherent services for all who seek them is the strategy. We think that is a coherent response.

Could the Minister write to hon. Members to clarify what will happen to those who are currently on the PROUD trial? What will happen while there is a gap between the drug stopping and the new trial starting? That would be appreciated.

I shall be happy to provide that very important clarification.

We should not underestimate our progress on testing and diagnosing HIV. That is down to the campaigning and the very hard work of many people in this Chamber, and by the many campaign groups out in the community that are the bedrock of the service in this country and provide world-class services for people who live in the UK with HIV. However, as today’s debate shows, our way forward is not free of challenges, and we must continue to reflect on how we can best deal with and meet those challenges. I hope that the commitments I have announced today go some way towards reassuring Members that the Government take these issues very seriously. However, the Government cannot do it alone. I am sure that we can continue to rely on the wisdom and support of all those in this room and the incredible work of voluntary organisations, so that we can finally achieve our goal, which we have all been working towards for so many years: a world free from HIV/AIDS.

I thank right hon. and hon. Members for their time this afternoon. This has been a constructive debate, and I thank the Minister specifically for the commitments on extending the ring fence, for recognising that work needs to be done on the commissioning model and with regard to the work that PHE will be doing on a new action plan to support the pilots in addressing fragmentation and specification. Those announcements were all very welcome.

We have come a long way from HIV/AIDS being a death sentence. It is now a manageable condition. That is largely to do with drug breakthroughs but, importantly, it has been delivered through a co-ordinated response both from Public Health England and the NHS. I hope that this debate will help to avoid undoing the progress that we have made.

Question put and agreed to.


That this House has considered the all-party parliamentary group report Impact of Health and Social Care Act on HIV treatment.