World class commissioning for
better sexual health
Gareth Jones
Director of Scientific Development,
Bioethics and Sexual Health
World Class Commissioning
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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
•
•
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•
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.