Service modernisation and integration

1. Service modernisation and integration Kate Guthrie FRCOG FFSRH Clinical Director, The Sexual and Reproductive Healthcare Partnership, Hull and East Yorkshire. More Progress, Same Priorities? 10/09/09

2. 3 clinical areas to illustrate themes from Progress and Priorities Delivering holistic sexual health care Developing integrated services for contraception and STIs Reducing repeat abortion � the abortion and contraception pathway

3. Key themes from Progress and priorities relevant to the 3 topics System and financial reform; strengthened commissioning, competition and contestability between providers. Tariff/QOF, LES. Know the drivers and levers. Tackling inequalities; local solutions to local inequalities. Targeted prevention and support for vulnerable communities. Highest burden of ill health born by women, gay men, teenagers, young adults, black and minority ethnic groups and more deprived communities. Involving service users and the public. The requirement for Champions. Clinical and service delivery developments. Integration. Innovation. Diverse providers, new settings to reach the hard to reach and reduce inequalities. Address the wider determinants of sexual health. Role redesign using care pathways, training, safety protocols such as PGDs to increase flexibility and pave the way for new providers. Increases access and capacity. Multidisciplinary team; effect use of skills and members. Nurse autonomy. Greater self management; self taken swabs and pregnancy tests, central booking, condoms, IT access to health care Deprivation data from SHA 98% of people have internet access. See SHA data and confidentiality safety protocols such as PGDs has increase flexibilityDeprivation data from SHA 98% of people have internet access. See SHA data and confidentiality safety protocols such as PGDs has increase flexibility

4. Key themes from Progress and priorities relevant to the 3 clinical areas Technology; prevention, testing and treatment. New diagnostic technologies lead to greater accuracy, earlier detection, non-invasive sampling, rapid results. Increases capacity and efficiency. Prevention technology�PEPSE, HPV vaccination. Treatment technology: HIV, medical abortion. Technology; communication. Develop social networks, access information and results, health promotion. Internet, texting, care closer to home with self monitoring and sent results. Anxieties; internet buying of unregulated tests and drugs e.g. HIV test kits and mifegyne. Managed networks. Membership from full range of providers, user representation, shared quality standards and guidelines, explicitly defined care pathways between providers. Aim to promote and facilitate equitable service access and provision. Needs based approach to planning and delivery of sexual health services

5. Key barriers from Progress and priorities relevant to the 3 clinical areas No targets to drive service provision in contraception, HIV or sexual health promotion as in Chlamydia and GUM access. Choosing Health monies and monies in Baseline Budget not getting through to services. Disconnection between national priority and local action. Disinvestment in community contraceptive services Commissioners; inadequate numbers of bodies and time in work programme for specialist sexual health. Separate budgets/ holders challenging for strategic approach to commissioning integrated services. Tensions if provider conflict. Joint approach where communities straddle boundaries generally not evident. Poor data, poor evidence. Needs assessment not consistent, poor surveillance data for PIs, evaluation, needs assessment/ mapping, GP activity. Poor IT in FP. No central mechanism for making evaluations available to inform commissioning, disseminate examples of local innovation. Cut in community contraception ; struggle for full service provision, whilst training, governance and outreach.. Potential increase inequalities , widen the gap, increase pregnancies. GUMCAD, GUMAMM, devised KT31s, Choosing health monies 2/3 in 2006/7 LARC training hit due to disinvestment , lack of training capacity Cut in community contraception ; struggle for full service provision, whilst training, governance and outreach.. Potential increase inequalities , widen the gap, increase pregnancies. GUMCAD, GUMAMM, devised KT31s, Choosing health monies 2/3 in 2006/7 LARC training hit due to disinvestment , lack of training capacity

6. Key barriers from Progress and priorities relevant to the 3 clinical areas Integration and workforce development. Competition and conflict between providers, non integrated budgets, separate training structures and data capturing mechanisms and different models of service provision threaten collaborative models. Will be aggravated by contestability�competition at expense of co-operation. Insufficient local needs assessment to build capacity and workforce capability to address local priorities. Contraceptive services; no route map for developments and improvements. Disinvestment restricts provision, training, governance and standards, health promotion and public information. Condom dominance. Services are embedded in communities, address choice agenda, also address wider health concerns and supports shift from secondary to primary care; STIs, health promotion, psychosexual, abortion, fertility, sexual needs of older people. Clinical model too narrow: limited in addressing wider determinants of sexual health - poverty, social exclusion, inequality, education, stigma, links with drugs and alcohol. Impact on wellbeing, relationships, families, communities. Relevant to all stages in life cycle. Social attitudes and stigma. Most impacts the marginalised/ vulnerable; reduces access to information and services. Prejudice and ignorance in professions and public; impacts on HIV, STIs, young people in general and abortion care. Decision makers locally may be uneasy about prioritising stigmatised services, especially if no local patient voice or champion.

7. Progress and Priorities; priorities for action are Prioritise sexual health as a public health issue and sustain high-level leadership at local, regional and national levels Build strategic partnerships Commission for improved sexual health Invest in prevention Deliver modern sexual health services

8. Delivering holistic sexual health care To address the wider determinants of sexual health Health trainers Smoking cessation Kiosks: open access Drugs Box and Drink�s Angel packages Teenage Pregnancy Support Service (incl Dads� support) Bariatric services ReFresh: drugs and alcohol for adolescents The Quays (PMS for homeless/ rootless/ substance misusers) Training vessel Community Wardens Prisons

9. Developing integrated services for contraception and STIs Integration: the patient journey or joint working with minimisation of organisational barriers? To maintain choice, increase access, to provide seamless care and cut the customer journey Initially provider driven, supported by local mapping of services Now led by Sexual Health Modernisation Forum

10. Developing integrated services for contraception and STIs: 1999 Hub and spoke model chosen GU Medicine, Family Planning and Community Gynaecology, specialist Health Promotion, voluntary sector partner Aids Action (Cornerhouse Yorkshire), TPU moved in together to centrally located building (HAZ funding). Named the Sexual and Reproductive Healthcare Partnership Single budget for NHS providers Overseen by Partnership Board (RIP)

11. Developing integrated services for contraception and STIs Workforce development within Partnership: all new medical staff trained in GU and contraception to level 2 Some existing staff grades in FP trained in GU (became PWSI/GPSIs) Increasing numbers of nursing staff became trained in both specialties Now have increasing number CASH clinics as opposed to GU and FP clinics Outwith Partnership: development of PWSIs, enhanced nursing role, increased role of pharmacist, etc .

12. Developing integrated services for contraception and STIs Workforce development within Partnership: Enhanced the role of the nurse; competencies, prescribing, PGDs Increased numbers and extended roles of support workers Introduced self triage Procured budget for outreach adolescent nurses Increased voluntary sector/ community partnerships GU consultants use their DFSRH and LoC competencies

13. Developing integrated services for contraception and STIs Partnership working TPU: funding source, Teenage Pregnancy Support Service, Young Mums Group and School, SRE, etc 1st Floor in central site is a drop-in run by Cornerhouse; buddy up to clinical services Voluntary sector: many condom outlets, static, community and street based. Chlamydia screening. Pregnancy testing.HIV support. CSW support. Peer education. Pharmacists; initially chlamydia screening only Prisons Pregnancy Advisory Service Integrated Care Pathway HIV: links with Infectious Diseases, becoming HIV Centre Community Gyn access to Acute Trust through joint contracts of consultants (RIP: staff SLAd to Drugs and Alcohol incl in maternity) Needs assessments e.g. LGBT needs, mapping

15. Developing integrated services for contraception and STIs Pathways Abortion integrated care pathway National Chlamydia Screening Programme Community Pharmacists: Emergency contraception, repeat issuing pills and patches, chlamydia screening and treating To adolescent outreach nurses To LARC To complex contraception, GUM, HIV, erectile dysfunction, community gynaecology, abortion care, training To/ from drug and alcohol key workers For methadone prescribing for daycases/ inpatients For Bariatric patients

16. Pathways Clinical Pathways for Long Acting Reversible Contraceptives (LARCs) Pathway (1) General consultation for contraception (adapted from NICE Clinical Guidance October 2005) Pathway (2) Implanon fitting Pathway (3) Implanon removal Pathway (4a) for irregular/prolonged bleeding with Implanon Pathway (4b) for irregular/prolonged bleeding with Depo-Provera Pathway (5) IUD/IUS fitting Pathway (6) IUD/IUS check &/or removal Pathway (7) for irregular, prolonged and heavy bleeding with an IUD/IUS Referral details to specialist services are included in Pathways (2) (3) & (5) Practical training is also available in Contraception & Sexual Health (C&SH) clinics for: (1) Letter of Competence in Sub-dermal Implants (LoC SdI) for Implanon fitting & Removal (2) Letter of Competence in Intra-uterine techniques (LoC IUT) for IUD/IUS fitting & removal Contact Training at Conifer House 01482 336378 Contraception Hotline � GP queries answered by email contraceptioninfo.gp@hullpct.nhs.uk Clinic guidelines available from www.ffprhc.org.uk / www.bashh.org.uk / www.nice.org.uk

17. Developing integrated services for contraception and STIs Support for the local provider community Training; medical, nursing, other healthcare and non-healthcare professionals e.g. emergency contraception Marketing and Promotions: also pick up PPI contraceptionadvice.GP@hullpct.nhs.uk Pathways

18. Developing integrated services for contraception and STIs To promote health/ self-care Education; itinerant trainer e.g. to hairdressing trainees HIV outreach worker Multi-media campaigns e.g. 2nd Time Around Kiosks; information, condoms and chlamydia testing kits Website

19. Developing integrated services for contraception and STIs Modernisation Forum, established 2008: aims Design and implement evidence-based clinical pathways and guidelines in respect to all sexual health services in the city of Hull Assess evidence and determine commissioning intentions to be adopted by the Hull Teaching PCT To lead and promote service development Secure and respond to user involvement and engagement Undertake regular Horizon Scanning of best practice and where possible apply this in Hull To be the bridgehead between the commissioning responsibilities of Hull Teaching PCT and providers of services (NHS or otherwise) Commissioner appointed 2009 (hurrah!!): future direction will be guided by a local strategy

20. Reducing repeat abortion � the abortion and contraception pathway Same lead clinician for both services Integrated Care Pathway since late 1990s; contraception discussed in pre-assessment and provided at procedure Longstanding full range of reversible contraceptives within local NHS provider of abortion service No budgetary restrictions when new contraceptives become available All abortion care clinical staff may not have formal contraception training but regular updating sessions/ full access to health promotional materials e.g. �1st Pill teach� materials, effectiveness chart. Fast-track to sexual health (contraception and GU) as part of pathway e.g. IU contraception post medical TOP

21. The pill has 10 times the failure rate of nova T, 40 times Mirena and 160 times the failure rate of implanon

22. Health Promotion �The Pill has 10 times the failure rate of Nova T, 40 times Mirena, and 160times Implanon.�

23. Surgical abortions % LARC uptake per year

24. Repeat abortions in Young People Repeat abortions in under 19s by PCT of residence, 2008 (TPU) England 11% SHA 10.5% Hull 5.7%; 4th lowest of all PCTs that put in returns Repeat abortions in under 25s by PCT, 2008 (DH) England 24.4 SHA 22.0 East Riding 13 Hull 16 2nd and 6th lowest in England

25. The Future? Not just more of the same! Because the PCT now has a commissioner and as a provider will be outside the NHS. plus Financial constraints plus local and national drivers and levers = excellent opportunities for innovation and change provided some capital monies to do so. Opportunity is missed by most people because it comes dressed in overalls and looks like work. --Thomas Edison

26. kate.guthrie@chcphull.nhs.uk