Trust integrates its sexual health services to improve access and delivery of services, providing a one stop shop for patients and reducing unnecessary follow-up appointments by 50%

The successful integration of Sheffield’s three sexual health services has resulted in a 50% reduction in unnecessary follow-up appointments and improved access to those most in need. Against a backdrop of ever-tightening NHS budgets, a total of 23% savings (£1.2M) have been delivered over the last two years, with the latest quarterly patient satisfaction survey reporting that 99% of patients rated their clinic visit as good or excellent.

Through the creation of citywide ‘one stop shops’, service users can now have all their sexual health needs met in one location rather than being required to attend separate services at different locations.

Challenges

•Prior to integration the services had historically inconsistent and well embedded professional, social and managerial cultures

•The two clinical services had differing clinic models (one medical and one nurse led) with conflicting processes leading to lack of streamlined services

•Sheffield Contraception and Sexual Health Services (SCaSH) and the Centre for HIV and Sexual Health were both community based services, Genitourinary Medicine (GUM) was an acute service. Therefore we needed to break down the barriers to enable the integration of community and acute services

•The pre-existing funding streams had negatively promoted competition between the two clinical services, creating a level of animosity between staff (one service was funded via tariff and the other by block contract)

•The existing services were delivered across three sites within the Sheffield locality

Actions

•Stakeholder engagement and input was pivotal to the success of the redesign of the services and therefore we undertook a programme of robust stakeholder involvement which included all staff, from all sites, across all professional groups. This engagement was designed to help the service work towards a joint vision and strategic aims and objectives in order to promote ownership as opposed to ‘buy-in’

•Undertook an initial staff consultation to enable the development of a new single integrated management team including the appointment of an Integration Project Manager

•Engaged a multidisciplinary Integration Project Group to coordinate the actions required to deliver the change. At this stage a ‘Patient and Public Engagement’ workstream was formalised and developed to implement a series of patient and wider stakeholder engagement interventions. This was to ensure the patient voice was pivotal to discussions during the change process

•Considered the implementation of ‘quick wins’ in order to motivate pockets of staff. These included: the offer of immediate cross site working for interested clinicians in order to build understanding across services, engage staff in identifying for personal and professional development improving morale and their knowledge and skills; and the development of a new citywide integrated health advisor team which streamlined patient pathways, creating a more robust partner notification service, with common systems and processes

•Established close collaboration with commissioners leading to the development of a citywide network. This was through multiple stakeholder events developing a local needs assessment to inform a cohesive model of sexual health service delivery across the local provider network including primary care and community pharmacies

Results

•Fully integrated sexual health service, delivered via a hub and spoke model, 64% of nursing staff are dual trained to deliver holistic contraception and sexual health consultations

•A city wide Partner Notification Service that has developed and sustained over-achievement against national standard. This service has also quickly contained two gonorrhoea and one syphilis outbreaks in Sheffield through its robust systems and development of a citywide outbreak policy

•Appropriate revision of follow-up protocol leading to a 50% reduction unnecessary follow-up appointments by introducing a clinical review system whereby follow-ups can only be booked if approved by the duty doctor (senior clinician)

•Comprehensive triage system that appropriately directs service users to the most appropriate level of care which is underpinned by robust pathways and handover criteria – thereby releasing capacity for Doctors/Consultants and Nurse Specialists to see more complex cases thereby improving access to those most in need

•Successfully undertaken two staff consultations in collaboration with unions in order to facilitate the redesign of roles and enable staff redeployment in order to meet the correct capacity for the new service

Value

•The service redesign has to date delivered in excess of £1.2 million against the contract value

•Using appropriate staff to direct resource effectively. Introducing a “Duty doctor” to support the Clinics run by doctors and nurses – this concept is excellent …. and provides Clinical leadership in addition to supporting ongoing clinical supervision to the clinicians. It is invaluable for training’ (Peer Review 2015). This has allowed a reduction in consultant whole time equivalent by 10 PAs.

•Role redesign and staff development resulted in appropriate task shifting and the development of ‘express/rapid’ clinics which now account for 50% of all clinic activity. Increasing job satisfaction for nurses, this released capacity for specialist staff to undertake more complex care and enabled open, fast access for patients requiring rapid services

•Quarterly patient satisfaction survey (September 2016) reported 99% of responses rating the service as good or excellent

•A Peer Review was undertaken in 2015 underpinned by national guidance and policies which highlighted the following: ‘Last 2 years have been very difficult and the pressure to save 11% followed by 4% of the budget has been very challenging. The service has delivered on these savings without significant effect on the service standards and access – highly commended’

In detail

Ambition

In the wake of the challenging economic climate and introduction of the competition agenda, Sheffield recognised the need for substantial redesign in order to protect high quality services for patients by ensuring that the service was patient centred, cost efficient and that it delivered value for patients, staff and commissioners. It was felt that such focus would result in a sustainable, flexible and viable service which could survive the future context of competition and fragmentation.

Our aims are to:

•Deliver a patient centred, integrated, holistic approach to sexual and reproductive health promoting ‘Every contact counts’

•Improved access and outcomes for patients by developing dual trained (contraception AND sexual health) clinicians to reduce unnecessary additional clinic visits

•Innovative nurse led services delivering easy access and cost effective pathways

•A highly skilled, integrated workforce delivering flexible, high quality comprehensive care

•Improved opportunities for staff development leading to enhanced motivation

•Building a culture of shared learning and peer support

Outcome

A fully integrated service delivered via an open access hub and spoke model, working in clinical and non-clinical settings to provide holistic, diagnostic, treatment, care and patient management services is now provided. The service is supported by a citywide prevention and promotion strategy and a training function to improve knowledge and skills so that the wider community can deliver effective sexual and reproductive health messages directly to the most at risk groups of patients.

Despite a significant reduction in budget, the efficiency of services provided has improved, with qualitative and quantitative data suggesting improvements in patient care and satisfaction. An independent Peer Review by another Trust was sought to support continued development and service improvement.

Feedback was highly positive, with the service receiving the following commendations: ‘Development of skill mix through the rapid and express STI clinics led by junior nursing staff and healthcare workers has enabled increase in capacity’. ‘Process of integration has been managed well with good foresight, planning and communication – highly commended’ As well as increasing efficiency, the service has increased performance against numerous performance indicators including increases in the percentage of women under the age of 18 having access to and being prescribed long acting reversible contraception; increases in young people’s uptake of chlamydia screening and HIV testing which is a cornerstone of diagnostic and opportunistic prevention message delivery.

Spread

The team work collaboratively with commissioners, primary care, representatives from the CCG, Clinical Directors and the Trust’s Executive Team in order to achieve the best services for patients. This has enabled a network approach to developing clinical services across the city, supporting pharmacies and primary care to provide sexual health services local to patients to improve access and delivery of services.

A training strategy has been developed to increase capacity and capability across the network. To improve access to services and reduce health inequality we developed a prevention and health promotion strategy including the use of multi social media platforms to engage and inform hard to reach and high risk groups. Our social media strategy is part of wider approach to engage those ‘less seen’ patients and reduce unmet need.

The sexual health training function was also redesigned to support the service to deliver a clinical and non-clinical training programme, thereby building community capacity to deliver high quality sexual health messages/information and support was pivotal to the training strategy. Staff training in clinical skills, safeguarding, research and service improvement methodology has been a priority so that staff are empowered to deliver the best care but also feel valued and we drive forward improvements.

Value

Through substantial support and engagement from staff and patients, the service integration and re-design has now successfully reduced costs by £1.2m whilst maintaining access and excellent patient care.

A number of initiatives have contributed which include:

•Role redesign and staff development resulted in appropriate task shifting. This has resulted in the development of ‘express/rapid’ clinics which now account for 50% of all clinic activity. This has increased job satisfaction for nurses, released capacity for specialist staff to undertake more complex care and enabled open, fast access for patient’s requiring rapid services

•Streamlining processes, procedures and reducing non-pay costs by effective procurement ensuring best value, e.g. a collaborative working group with pharmacy looked at drug costs, simplifying stock drugs and thereby reducing costs reduced our drug budget by 30k.

•Release in capacity as a result of redesigned roles lead to additional services for high risk groups including the development of Pitstop+, a weekly drop in service for men who have sex with men (MSM)

•Results from our quarterly patient satisfaction questionnaire – average responses 200 – last survey 99% of respondents rated the service excellent/good

•The roll out of a ‘microsystems’ approach to small change has empowered staff and is contributing to a new, sustainable culture of continual service development Involvement

All primary stakeholders were engaged from the outset via a series of 3 time-out events. These explored the opportunities and risks of integration and developed a collaborative vision in order to promote ownership of the change. The integration project team engaged staff in a number of multidisciplinary workstreams which provided support to the project. Within this structure the Patient and Public Engagement Group (PPE) led a number of initiatives including a patient consultation exercise, quarterly patient satisfaction questionnaire, mystery shopper exercise and ‘You said – we did’ board in clinic.

A number of initiatives were run to engage staff including time-out sessions, protected time for weekly staff group meetings/training, suggestion/comments boxes, staff newsletter and a biannual ‘bake off’ competition. Commissioners were involved via the Integration Project Board; Strategic Communications Group and Contract Monitoring and Performance Group. GPs, third sector and voluntary providers were able to have their say on the relocation of the service through email, online and GP channels communications.

Third Sector engagement was continued via the existing links. In addition to the patient engagement group we have a rolling programme of young (aged 16-20) peer educators who deliver sexual health information and education to young people in Sheffield schools, colleges and other youth/community settings.