World class commissioning for better sexual health Gareth Jones Director of Scientific Development, Bioethics and Sexual Health World Class Commissioning • • • • Improve the health of the local population Reduce health inequalities Ensuring safe and sound health services Ensuring best value Tackling Inequalities and Improving Sexual Health Poor sexual health disproportionately affects people experiencing other health inequalities, with young people, gay men and some black and minority ethnic communities experiencing the poorest sexual health. Public Health and the Commissioning Cycle • Strategic Planning: Leadership; needs assessment; health impact assessment; health equity • Procuring Services: Advise contestability and commissioning processes • Monitoring and Evaluation: Develop indicators for sexual health and inform performance indicators People increasingly expect to be able to make choices… From… To… ‘You can have any colour, so long as it’s black’ ‘…Colorado red, moon dust silver….’ Choice and competition • • • • Ensure safe quality care Greater emphasis on individualised care Better value for money Stimulate innovation Making A Bigger Difference: A guide for NHS front-line staff and leaders on assessing and stimulating service innovation (NHS Institute for Innovation and Improvement) “If we continue to do what we’ve always done, we will get the results we have always got” “Without change there is no innovation, creativity, or incentive for improvement. Those who initiate change will have a better opportunity to manage the change that is inevitable.” (William Pollard) The 5 steps of Lean Define Value Specify Value-stream Pull Flow Pursue Perfection Lean Thinking and World Class Commissioning Can Transform This… Referrals from GP, CASH, youth, outreach, school nurses, practice nurses, CSP, prisons and young offender inst. GUM Partner Notification Patient, provider, contract referral Self referral (majority 70%) Secondary care e.g. Obs & gynae, A&E GUM UHND, DMH, Escombe Rd Level 1,2,3 Can we control who accesses the service? CASH Pharmacies, Recalls by Health Adviser, Police, Sexual Assault Referral Centre PSA 11b 48 hr access Have the recommendations from the GUM review been implemented at all sites? Reception How do we develop L3 to include CASH? How do we ensure that patients are booked with the appropriate practitioner? Team Asst bloods, chaperone, show to room >50% people accessing HIV treatment and care are MSM Occupational health, secondary care, Prisons No provision in CDD for HIV support for BME community Are the staff roles standardised in all 3 sites? How many staff are dual CASH/GUM trained? All testing, treatments, dermatology, HIV treatment & care Could the service use an automated result system Voluntary Orgs / Local Authority MESMAC, GADD, LGBT Asymptomatic screening, some symptoms, treatments (using patient group directions), vaccinations HIV PCT / Primary Care CSP, GP, Level 2, CASH Specialist Services (Teesside Positive Action) Referral from other agencies i.e. CASH, midwives, CSP, youth services, Health Visitor, Connexions, school nurse, DAAT, looked after team, learning dis team, refuge, homeless Is this a provider or commissioning function? HIV Test Advice, support, condoms Rapid HIV Test (Substance Misuse Only) Self Referral Drop in Telephone Text When can people referr Role arose from and funded by (ends 2008) Teenage Pregnancy Strategy Support Workers 2.3 wte East PDA (few self referrals) SHOW 2 each PDA (some posts vacant) Referral to CASH, GP, counselling, vol orgs, social services etc Discharged home HIV Test Advice support, condoms May refer to lab for test Who provides supervision community venue 1:1 support Home or Are testing and referrals standardised Should we offer to general population? Community Venue Support for young parents and parent to be Deliver training programmes e.g. ante-natal programme Core Functions: Capacity Building 1:1 C-Card Do we need to ensure more practices can run enhanced services (LES) Cash services could enhance their role ? Chlamdyia screening service could enhance to level 2 ? Could GUM do out reach instead of only secondary care ? How many GPs currently understand the International coding / contract tracing system ? Referrals from community, sure start, health visitors, CASH, School Health Refer to other partners e.g. midwife Discharge Should we offer to general population? Refer for PEP GUM A&E Positive Result Negative Result Refer to GUM Treatment & Care Partner Notification Retest Discharge Core function: Core function: May also offer: Chlamydia screening C Card May also offer C Card Chlamydia screening Discharge Review Refer Review Discharge Refer Review Discharge Refer Refer GUM CSP TOPs Other providers Refer GUM Vol orgs/LA CSP Refer GUM Vol orgs/LA May also offer: Pregnancy Testing Chlamydia Screening Texting service NPDA Low volume chlamydia screening Can we improve this? Can SHOWs prescribe e.g. emergency contraception? Would this be useful? How do we raise awareness with professionals to test May support through referral e.g. accompany to TOPs appt Letter to referring agency (where appropriate) Review Ration new:follow up 2:1 How do people access the services available through primary care How do we advertise ? Should we have a central number ? Treatment and follow up or discharge Refer to GUM for Partner Notification pathway. Pathways are not standardised between services. Is everyone aware of the process or need for PN Training, skills and support will vary. Do we know how many PN are Family Planning or GUM trained ? GMS Contract level 1 services Core business Practice Nurse Level 2 Service LES / PBC STI testing, treatments Practice Nurse Peaseway Practice Nurse Level 1 or level 2 services Refer to CASH Is Nurse Prescribing from general practice transferable to community services ? Refer to secondary care TOP and GP Chlamdyia screening centre for results and treatment and partner notification GUM (Only offer EOHC and condoms, must refer) CASH clinic reception Some venues shared with other providers Drop-in or appointments Some staff will offer some STI tests Medical staff Ref to nurse for treatment Nurse Consultant Vacant post Testing, chlamydia screening, treatments, condoms, pregnancy testing, advice STI testing (including chlamydia screening) treatments, condoms, pregnancy testing, advice Review Discharge Clients may be referred from a number of services Do we need a central booking / advice system to ensure access to appropriate service 1st time? Domicilliary E.g. in drug services when required Home visit Some resistance from band 5 nurses regarding scope of practice 1 offering level 2 STI testing East PDA Schools & Colleges With Health Visitor / School Nurse Contraceptive treatments, Advice Chlamydia screening, condoms Can CASH staff follow up chlamydia screening, give result, treatment, partner notification? Ref to CSP for chlamydia screening result & partner notification Refer HIV Prevention GUM, CSP, GP Secondary Care, TOP/ scans, SHOW, midwife, school nurses Only 1 proposed combined CASH/ GUM session in CDD Can we develop these? What would be staff training needs? Referral from GP, Practice Nurse, CASH, youth services Why such a low uptake How do we achieve high volume screening What are the barriers Clinical (33%) GP (wont test & barriers with reception staff i.e. time constraints) Practice Nurse CASH School Nurses Health Visitors Termination Services need to avoid repeated waits to see different health professionals at sessions with all HPs completing care and treatment at one 1 Specialist Nurse each consultation area 6 Team leads CASH Nurse Not all nurses GUM/STI Staff training and trained supervision should be Use of PGDs but may mutually reciprocated with need to see Dr/Ext NP for GUM prescription Results can take 2-3 weeks How do we ensure world class commissioning of lab services Is there an SLA? If so can we amend? Primary care Core services Some enhanced LARC GAP in service to prisons CASH If referred by HCP results come back to practice Training, skills and support will vary. Do we know how many GP are Family Planning and/or GUM trained GPs Brandon Darlington College (due soon) Consett -Queens Road Bishop Auckland CASH Nurse Specialist Local Area Awareness raised through social marketing e.g. radio Materials e.g. posters leaflets Website It is the GP responsibility to ‘know’ about the service rather than the CSP’s responsibility to ‘inform them’ Other providers e.g. GP (any area or GP they are registered with), practice nurse, school nurse, youth servcies etc CSP (Only offer EOHC & condoms, must refer) male : female ratio 99% female Sometimes staff experience problems in accessing venue Other providers reluctant to share clinic space Letter back to GP if letter was received from GP GP Ongoing support Is there a standard and pathway for referrals? CSP Chlamdyia screening / postal packs Self referral Partner Notification Mostly Level 1 (may not get full service) What are links with rapid HIV testing, substance misuse Young people felt that SHOWs should offer EOHC Return for treatment Or Uncontactable need treatment What is defined as core services. Should Chlamydia be ? GP Level 1 or level 2 services Geographical Inequality Is this targeted against greatest need or a funding restriction? Seen in community SHOW Primary Care Reception / entry point in Self Referrals Appt System Walk-in (only if enhanced service (4 practices only out of 109) HIV Prevention Specialist 1 wte South PDA What is the core function? Refer to GUM How do we prevent late presentations for test? Referrals into Primary care What do we understand about current referral patterns into primary care, who, where, appropriate ? Are these staff working in silo’s? What is their communication platform? Young Mens Worker 1wte Sedgefield & Dales Review Discharge Young people outreach worker for pregnant young girls What happens when that worker is off sick or during holiday periods? Are SHOWs matrix working and providing cross cover? Geographical Inequality Is this a targeted approach or a funding restriction? Secondary Care Tertiary care GUM Refer for social care & health support Text / Phone for results 7-10 days later Can we develop a one stop shop GUM/CASH/CSP? Is there a referral pathway? Who picks this up when SHOW not at work? Influenced by HIV Trainer Do all SHOWs perform core function as main role: Leaflets and information Inequalities for prison population, access and service How does the service incorporate prison staff? Substance misuse What education do we have in schools? Nurse Practitioner Advice, support condoms Sexual health advice, bloods & vaccinations, partner notification, treatments Referrals from other agencies e.g. School nurses, CASH, GP, youth services, CSP, (clinical & non-clinical) Education GUM Consultant / Dr Health Adviser Self referrals Inc some LGBT community and from outreach near pt testing/Hep B events Partner Notification Influenced by Health Improvement Leads Can some of the vol orgs offer HIV testing? HIV Prevention Specialist Can we have generic nurse practitioners to incorporate this role? Sexual Health Outreach Are we offering 100% access? May be public misconceptions around screening Some stakeholders did not know this Lack of consitency between test initiators Central Office Barriers around screening young people Home Visit Not effective working Screening events e.g. colleges Postal service Health Adviser HCA Admin Health Adviser Need to renew pathways for those staff who do own treatments etc Health Advisers also offer emergency oral hormonal contraception, pregnancy testing, condoms What is the return from postal packs ‘v’ cost of packs? Test Initiator Non-clinical (66%) Housing Assoc Youth workers Is the current request form a barrier to screening? Can the testing form be simpler? Can standard microbiology form be used? High male / female ratio Self referral – need simple form Screening event Postal service need easier pack At CSP clinic sessions As a contact Chlamydia Screening Outreach Clinic Health Adviser Test given / sent Client receives result from central office can take up to 3 weeks Central office Treatment Retest (if pregnant) Partner Notification Discharge Letter to clinicians (creates large demand on workload for central office) How efficient are the lab services? Is there equity of service - are noninvasive methods available to all practitioners (male and female)? Is the lab service value for money? Level 2 service (1 only Derwentside) TI’s have problem in acccessing results from lab as lab staff recluctance to give out Also have training role Distribution of resources Does the central office have the resources / need to offer all treatments, PN etc? Can the providers perform these roles? Referral to GUM Referral to CASH Referral to specialist service e.g. psychosexual counselling, TOPs Clients may need more than one referral, this may be a misconception Too much time spent chasing clients Distributing resources: Ineffective use of HA time, not cost effective ...to this Common Sexual Health Pathway NEED GENERAL AWARENESS IN POPULATION Websites Advertising NHS direct Awareness raising events Social marketing Capacity building & training Newsletters Posters Adverts phone book Outreach health events (schools, colleges) Networking/joint working Admin office Sign posting to sessions Shared care with GUM/ CSP Quarterly reports Leaflets Shared events Appointments available Open access (drop-in) Need: shared database/ I.T. system Targeted services & shared social marketing approaches Central phone number Shared advertising BOOKING SERVICE ACCESS TO SERVICE Getting to see the right person ASSESSMENT PROCESS Confidential service Dependent upon info received from client Drop-in sessions Ensuring capacity One stop shops -triage of clients Domicilliary outreach service Information sharing protocols Shared pathways Triage system Risk assessment/ criteria all need to link to CAF Could have shared job desriptions/roles Dual trained staff, documentation and pathways National framework Need: I.T. combined system compatible with all services Unique: High risk (e.g. gay/ bisexual) Inconsistencies in roles e.g. SHOW:CASH Unique: 48 hr access (GUM) SHOW unique access HIV prevention post required across County Durham & Darlington KEY Commonalities Unique to area DIAGNOSING THE ISSUE Testing, screening, management Lab isues Medical / sexual history Referral to CASH/GUM/ TOPs etc if inappropriate appointment history taking Unique: Microscopy (GUM) – is this necessary? Age specific (CSP) TREATMENT Medication, surgery, advice, education Free treatments Procurement issues e.g. pharmacy supplies PGDs Prescribing Shared protocols, info, leaflets, PGDs (primary care/CASH/CSP) Unique: Same day treatment GP clients pay for L1 Rx HIV Rx (GUM) Need: Standardised competencies for staff working in contraception and sexual health services MANAGEMENT OF RELEVANT OTHERS (e.g. partners) Partner notification or ref for PN Peer support VD regs REVIEW Follow up process Frequent users not identified Refer to appropriate service Follow-up Text results service END OF EPISODE Outcome, actioned and documented Notes storage systems capacity issues Recall Referral to appropriate service for additional care e.g. CASH, GUM Robust pathways Service user evaluation/PPI Quarterly reports, stakeholder events Unique: No CASH I.T.