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1.       Developing a Commissioning Framework that responds flexibly, sensitively and creatively to the variety of needs that people with HIV have.  This framework should be committed to:

• The personalization of outcome-focused services using direct payments and personalized budgets to promote person centered planning and flexible, individualized packages of support that provides choice to service users wherever possible.
• Ensuring that service users are able to self-refer, access provision easily and that referral pathways between services are clear easy for service users to negotiate. 
• The commissioning of services which deliver required provision within budgetary constraints and which demonstrably provide value for money. 
•  An agreed joint vision between sectors and organizations for the future planning and delivery of services, designed to support co-ordination and reduce any overlapping provision, which is supported by clear service delivery specifications and service level agreements.
•  Enabling a collaborative approach to service commissioning and delivery that allows commissioners, providers, service users, the voluntary sector and other stakeholders to inform service commissioning and delivery.
• Ensuring that key values (particularly anonymity, confidentiality, equity, accessibility, participation and respect for dignity) are explicitly considered by commissioning and that the commissioning process ensures these values are incorporated into commissioned services.
• Ensuring that services are able to reach those groups that are most at risk from HIV/AIDS.  This means commissioning must ensure services are appropriate to gay men and Black Africans who are currently the most at risk groups.
• Ensuring that multi-agency care packages are sufficiently flexible to deal effectively with changing individual circumstances (which can be cyclical) and able to meet non-acute needs.

2.   Needs Assessment

Commissioning may be used to ensure effective need assessments for people with HIV/AIDS are in place.  To do this, commissioning could be used to:

·        Support the development and application of a needs assessment process that is able to identify the individual circumstances of people with HIV/AIDS – including those with complex needs.

·        Ensure the development of effective needs assessments that are, where possible, able to support preventative activities so avoid crises.

·        Enable service users to articulate and prioritize their needs and how these should be met as a part of the needs assessment process.

·        Take account of the potential secondary impacts of interventions (such as the side-effect of drug treatments).

·        Consider broader quality of life issues, rather than simply health and illness-related issues.

3. Models of Service Delivery

A number of service delivery models may be used to meet the needs of people with HIV/AIDS which commissioning may develop and support.  Commissioning needs to consider which model (or which combination of these models) to maintain and develop based on available financial resources, national policy legislation, frameworks and guidance, evidence of need and key issue to address.

Floating Support

Evidence suggests that floating support is able to provide the flexible, person centered services that enable people to establish and maintain their independence.  It also indicates that this can be achieved in a way that reflects national policy requirements and good practice.  A review by Civis[2] found the benefits of floating support include:

•  Delivery of health and social care outcomes including the prevention of re-admission to hospital, improvement to quality of life and support to enable independent living.
• Provision of support irrespective of the type of accommodation people live in.   Floating support workers can also provide advocacy for service users. Services can be flexible and respond to emergencies. 
• The level of support can be tailored.
•  The support worker may act as a broker to other services.

Generic or Specialist Models

There remains an ongoing debate between stakeholders as to whether support services for people with HIV/AIDS should be generic or specialist. In this context, it may be useful for commissioning strategies to note that:

•  Many HIV advocacy organisations regard specialist provision more positively, believing this model supports the development of specialized knowledge among practitioners who can work in partnership to provide care and support. 
• Research into local support provision in Newcastle found many service users prefer specialist provision rather than provision for people with HIV being integrated with provision for other chronic illnesses.

Commissioning needs to consider which of these approaches to use or how to combine both approaches in the context of local issues, local preferences, budgetary constraints and national policy requirements relating to flexible, person centered services. 

Cross Authority Commissioning

It may also be worthwhile for commissioning strategies to explore the potential for support services, for people with HIV/AIDS, to be commissioned at a cross-local authority level.  This has been suggested as a way to provide cost-effective services when there is less need for, or only small numbers of people requiring, support[3].

Support Services

Recent national and local level research[4], suggests that commissioning for services for people with HIV/AIDS should focus on the maintenance and development of services across a range of areas if it is to ensure that their needs are met.  These areas are:

Social care and support

To meet the social care and support needs of people with HIV/AIDS services need to provide support for self care, support to undertake domestic tasks, assistance with the care of children and mobility-related support.

Housing

The effective management of HIV requires that anti-retroviral drugs are stored properly, taken at the correct times and that they are taken with or without certain food.  This difficult to achieve for an HIV positive person who is homeless or lives in insecure accommodation. Evidence from the USA and France also suggests a lack of secure accommodation can make attending medical appointments very problematic which makes it more difficult to manage HIV.   Therefore, commissioning needs to explore how to ensure people with HIV/AIDS are able to access secure housing.  As financial resources allow, it would therefore seem useful for commissioning strategies to support and develop provision that:

•  Considers the extent to which local authority allocation policies enable priority  to be awarded to people with HIV for social housing on medical grounds on the basis on a comprehensive needs assessment and support any changes where this is deemed necessary.
• Ensures that people with HIV who are also homeless (or at risk of homelessness) are always considered vulnerable and that they qualify for emergency support and appropriate priority on housing registers, regardless of their current health.  This would support housing allocation policies to reflect the fact that HIV can be a fluctuating condition. 
• Limits the use of shared accommodation so that people with HIV live in shared accommodation for the minimal amount of time, unless it is clearly demonstrable that shared accommodation is appropriate.
•  Identifies if warden aided provision needs to be modified and supports this where necessary.
• Maximises the amount of affordable housing that is available for people with HIV/AIDS in the local authority, private rented and housing association sectors.
• Ensures appropriate housing advocacy and advice provision is available. 
• Explores the potential role of Extra Care and/or Concierge Plus models as housing options for people with HIV/AIDS so that they can retain independence yet have access to housing-related support when this is required. 
• Investigates opportunities for using assistive technology in a range of housing settings to further facilitate independence and tailor support to individual need. 
• Considers the potential for using telecare as a model of support to support people with HIV.

Financial security

To help to address financial security issues that people with HIV/AIDS can face, commissioning could consider developing provision that enables people with HIV/AIDS to access information and advice about benefit entitlements and budgeting. 

Education, training & employment

Commissioning to provide education, training and employment support to people with HIV/AIDS could include ensuring service providers are able to provide information about and pathways to education, training and employment, alongside support to deal with any education, training and employment related discrimination. 

Healthcare Needs

To ensure healthcare needs are met, commissioning could support services that provide information, services and appropriate referral pathways to enable access to preventative services, treatment, information about living well with HIV, services that address the side effects of HIV drug treatment, support to deal with drug and alcohol dependency and services which provide support in relation to appetite and eating and sleeping. 

Support Groups

Evidence strongly indicates that support groups which enable people with HIV/AIDs to meet together safely and seek support are important.  As such, commissioning should consider how it can support the continuation and development of these groups. 

Befriending and Counselling

Befriending provision and counseling could improve the mental health & wellbeing and motivation of people with HIV. It may also potentially reduce anxiety and depression and help to reduce the problems some people with HIV can experience with household chores and self-care.  As such, it may be useful for commissioning to explore the potential to support and develop befriending and counseling services. 

Mental Health & Wellbeing

Advocacy organizations working with people with HIV/AIDS have suggested a range of support provision that can be used to support the mental health and wellbeing of people with HIV/AIDS and which it may, therefore, be useful for commissioning to support and develop.  Suggested provision includes: 

• Psychotherapy. 
• Cognitive Behavioural Therapy. 
• Life Coaching.
• The provision of Community Psychiatric Nurse provision. 

Legal Advice

Commissioning could also be used to provide access to legal advice services for people with HIV/AIDS.  This could include supporting the provision of information and referral to specialist provision in relation to residency claims where appropriate.

Young People

Commissioning could be used to consider how the needs of a potentially relatively small number of young people with HIV/AIDS can be supported. In this context, commissioning could be used to ensure effective links are in place between practitioners and that young people are provided with information, advice and guidance across a wide range of areas (including treatment options, housing, finance and mental health and wellbeing) so that they can transition into adulthood as easily as possible. 

Reducing Stigma

Stigma associated with HIV/AIDS may impede people testing for HIV and using services once they learn they have HIV.  This puts people with HIV/AIDS at greater risk of social exclusion.  In this context, it would seem useful to consider how commissioning can be used to reduce stigma relating to HIV/AIDS so that access to and uptake of provision is improved, HIV-related mortality is reduced and to ensure people with HIV/AIDS have the best quality of life possible.  To reduce stigma, it may be useful for commissioning to consider:

•  If practitioners who work with people with HIV/AIDS require training to address any myths relating to HIV and its transmission. 
• How it can be used to ensure that service providers explicitly demonstrate to service users and potential service users their commitment to anonymity, confidentiality, equity, accessibility, participation, respect for dignity non-discriminatory practice. 
• Supporting the use of open day/evening sessions and of people being taken along to support services by a trusted individual (which local research suggests may encourage people with HIV/AIDS to access provision).

User Involvement

To meet statutory requirements and good practice guidance, commissioning strategies will need to ensure that people with HIV/AIDS are able to influence commissioning decisions, service delivery and feedback on services that they receive.  Commissioning strategies will therefore need to ensure that commissioned services provide opportunities for service users to influence delivery, provide service users with appropriate choice and enable service users to feedback on the appropriateness of the support that they receive.

The Voluntary Sector

‘Effective Commissioning of Sexual Health and HIV Services’[5] highlights that the voluntary sector has an important contribution to make to the modernization of services for people with HIV as a result of its knowledge and expertise, understanding of local need, its positive reputation with patients/service users and its efficiency.  It also stresses the potential social care role of the sector and its ability to provide signposting, advice, information and advocacy provision.  Local level research also highlights the important role the voluntary sector in the provision of support services.  In this context, it would seem appropriate for commissioning to develop service models that support the continuation, development and long term viability of the voluntary sector in the development and delivery of these support services for people with HIV/AIDS.  This may include developing longer term contracts with voluntary sector service providers. 

Service Monitoring

There has been a concern that there are few targets focusing on HIV/AIDS at a local level in England which makes it difficult to monitor the standards and impact of services.  As such, it may be useful for commissioning to develop service models that set measureable targets for services to achieve.

[1] Newcastle City Council Corporate Planning, Programmes and Research, Chief Executives Office & MESMAC North East (2009) Assessment of the needs of HIV-positive people using services in Newcastle.

[2] Department for Communities and Local Government (2008) Research into the effectiveness of floating support services for the Supporting People Programme, Civis Policy Consulting Research.

[3] See Walsall Council, Supporting People Needs Analysis

[4] Weatherburn, P et al (2007) The Growing Challenge.  A strategic review of HIV social care, support and information services across the UK, Stigma Research.

[5]  Mezzone, J (2003) Effective Commissioning of Sexual Health and HIV Services, Department of Health.