Modernisation Initiative - demand and capacity mapping in sexual health

Background

The Modernisation Initiative is a three year programme funded by the Guy’s & St Thomas’ Charity to improve and modernise stroke, renal and sexual health services in Lambeth and Southwark, an area in central London with significant sexual health need, including high rates of teenage pregnancy and STIs.

What is the problem you are trying to solve?

Before making any improvements, we needed a deep understanding of our current system of sexual health service provision. We had already recruited users to map the patient pathway and this gave us valuable data about problems with services. These included access, waiting and transit times, staff attitudes, lack of choice, a feeling of being “done to” by health professionals and inconsistency around giving negative results. However, we wanted to go further and answer questions including:

• Where do people go to get their sexual health needs met?
• When do people access services? Are there peaks and troughs in demand?
• What are the reasons for attendance?
• How long does it take to be seen?

What local organisations are involved?

The initiative works with Guy’s and St Thomas’ and King’s Foundation Trusts, Lambeth and Southwark Primary Care Trusts, and a range of voluntary and private sector organisations.

The demand and capacity mapping was carried out with three genitourinary medicine (GUM) clinics, three sexual and reproductive health (SRH) services, Brook young people’s clinics and a sample of general practices and community pharmacies in one locality. We gave primary care providers an incentive to avoid the pitfalls of only including those already known to have an interest in sexual health.

How many people are running this project and who are they?

We had one project manager with administration support. We also used “clinical champions” to generate support for and ownership of the project. A service lead and lead clinician were involved from each service. We hired some temporary staff to support clinics with data collection and entry, and a data analyst to pull out findings from the large amounts of data we collected.

What local population are you targeting?

Lambeth and Southwark have high levels of sexual health need. We wanted to understand the range of reasons for attendance from the very basic to the complex.

How many people are you targeting?

We wanted to understand who was accessing which service and why so we had no particular numerical target.

Interventions

What interventions are you using to address the problem?

Our demand and capacity mapping took place over one week. Staff in each clinic were briefed to collect information on every element of the patient’s visit from start to finish, including how long the whole process took, who dealt with them, their reason for attendance, and what was done. We made sure we recorded all demand, including individuals who were turned away. The emphasis was different in primary care where we recorded the number of appointments requested, the proportion of work devoted to sexual health and whether the patient was referred on to a specialist.

In terms of capacity, we recorded factors including the staffing profile, hours worked and rooms and equipment available.

Is the project design based on evidence? If so, please state reference.

The intention of the project was to generate evidence for change and the tools we used are well established. The NHS Institute Improvement Leaders’ Guides ¹ provide useful guidance. Recently, demand and capacity mapping has been recommended as the first step in redesigning sexual health services in order to meet the 48 hour access target for GUM services ² . Additional guidance for sexual health services will be published later in 2007.

Outcome

What outcomes or planned outcomes are you measuring?

We learned a great deal about our system of service provision including:

• Long waits are common at clinics, often in the first few hours of the clinic being open. However, this was often because clinic staff told users to come early to guarantee being seen;
• Different services cater for different needs – people with STIs tend to go to GUM clinics while those wanting emergency contraception tend to go to community pharmacy. Nearly a fifth of all appointments in general practice relate to sexual health and are usually managed without onward referral;
• Contraception, including emergency contraception, makes up almost half of all activity across all services, with much of it happening in general practice and community pharmacy;
• When the figures for community pharmacy were applied to the whole of Lambeth and Southwark, they suggested that around 4000 people with sexual health needs visit a pharmacy each week. That’s around three times the numbers visiting SRH and GUM services;
• The data from pharmacy suggests that “self care” is an important element of service provision and could be developed further;
• The most common reasons for attendance include asymptomatic and symptomatic STI screening, pregnancy testing and contraceptive pill supplies; and
• There was no evidence of a lack of capacity, but rather that capacity is not always matched with demand.

Do you have any outcomes or results yet? If so, what are they?

We used our findings to make short term improvements to services including:

• Self triage to enable patients to see the correct healthcare professional for their needs;
• Allocating slots throughout the day in clinics to prevent overcrowding and bottlenecks;
• Piloting self administered, non-invasive tests in clinics and in community pharmacy; and
• Measuring transit time data – this gives a quick and reliable measure of how long it takes for patients to be seen and shows the results, for example, of reducing the number of hand offs.

However, we realised that there was a limit to the improvements we could make to existing services and that ultimately the whole system of service provision needed to be reconfigured to deal effectively with increasing demand. Our new service model currently being implemented across Lambeth and Southwark involves:

• Identifying which sexual health needs really are “specialist” and therefore need to be addressed by senior clinicians;
• Dealing with basic needs in new ways, for example by developing the role of community pharmacy and of health care assistants; and
• Integrating STI and contraception services into new community-based sexual health centres where GUM and SRH providers will work together to provide accessible services open into the evenings and on Saturdays. The centres will focus on self management, cutting the amount of healthcare worker time needed and thereby allowing us to see a lot more people than we do now.

Is your project relevant to a government target or guideline?

The changes made as a result of the mapping will enable us to meet government targets around sexual health including the 48 hour access target for GUM ² . Our work takes forward the Medfash Standards For Sexual Health Services ³ and is mentioned as a case study in the Department of Health’s 10 High Impact Changes for genitourinary medicine 48 hour access ² .

Feedback

What obstacles did you have to overcome to set up this project?

There were few obstacles as such, but it is important to emphasise that a lot of preparation went into the project and into securing the engagement of clinicians and other frontline staff such as receptionists. Staff have to be able to see the benefits and be reassured that this is an exercise that looks at systems rather than individual performance. Staff need to be well briefed and somebody needs to be available for troubleshooting.

What have you learned about the project so far?

We now have a better understanding of our whole system of sexual health service provision and an evidence base for the changes we are making.

What would you do differently?

Some of the learning that we would pass on to others thinking of undertaking a similar exercise includes:

• Before you start the study, think about why you want to measure demand and capacity and how you will use the findings;
• Think about how wide you want to go – mapping GUM only will not give you the whole picture; likewise mapping all services will be time consuming;
• Be realistic about how long you want to collect the data for: a week might give you skewed results, three months might be unrealistic;
• Remember that demand is not the same as activity;
• Be clear about who needs to be involved, particularly in terms of making changes afterwards. There will probably be commissioning implications. Think about how you will sell the idea to clinic staff, for whom this will generate extra work;
• Don’t underestimate the amount of preparation required – staff will need written and verbal briefings and there will be unexpected problems along the way;
• Don’t collect more data than you need and can usefully analyse. Make sure the data collected answers your questions. Think about who will collate, analyse and present the data; and
• Demand and capacity mapping should not be a one off exercise; it needs to be part of a wider programme of service improvement. You will need to review any changes made and should repeat the exercise in future and mainstream it into routine clinic activity.

References:

1. NHS Institute for Innovation & Improvement. Improvement Leaders’ Guides. Coventry: NHS Institute. 2005
2. Department of Health. 10 High Impact Changes for Genito-Urinary Medicine 48-hour Access. London: Department of Health. 2006.
3. Medical Foundation for AIDS and Sexual Health. Recommended Standards for Sexual Health Services. London: Medfash. 2005.