This is the second in a series of three blogs exploring each stage of the sexual health commissioning cycle. It will focus on the first two stages of the cycle: analysing and planning.
It is essential to spend time on the first stages of the cycle, as it allows you to understand the needs of the population and effectively plan to meet them.
There is a danger that health needs assessments make generic, strategic suggestions to ‘strengthen’ or ‘improve’. However, without ‘SMART’ measures, we will never know whether we have achieved what we set out to do. Using these stages to determine the tangible things that need to change, and how we plan to make this change, is crucial to success.
Stage 1: Analysing and understanding population needs
In the UK, we have a wealth of data on sexual health service attendance and activity, epidemiology of STIs, HIV and contraceptive use, and an understanding of the population’s lifestyles and attitudes towards sexual health. The Sexual and Reproductive Health Profile includes a guide to local and national data, and there is guidance on how to undertake a sexual health needs assessment. PHE Centre colleagues, including sexual health facilitators, field epidemiologists, and knowledge and information colleagues, can assist in accessing and interpreting these data. However, there are some important principles to be aware of.
Activity and diagnoses do not equal need
Determining ‘need’ in relation to sexual health is complicated, as the level of service delivery will inevitably influence STI diagnosis rates and contraception take-up. For example, increases in service level usually leading to increases in STI diagnosis rates which could be misinterpreted as a higher level of need.
Nonetheless, we all recognise that identifying more infections and treating them to prevent onward infection is good for public health. Using activity and diagnosis rates alone as measures of need can be inaccurate and misleading, and there is a need to review both testing rates and the proportion testing positive to better understand whether there continues to be unmet needs.
Whilst the public health outcome measures are a good starting point to assess the effectiveness of local services, it is important to be aware that some measures are impacted by access to services and others are not. For example, chlamydia detection rates will be influenced by service access, but teenage conception figures are a combination of actual numbers of births and abortions.
With limited resources, it is important to focus on populations in greatest need. Looking solely at activity or diagnosis rates does not tell us about unmet need in the community; not least because it may be that those at greatest risk of poor sexual health are not attending services.
So, how do we understand need?
It is important to start with a detailed understanding of the local population’s demographics, and consider this alongside what we know about sexual health needs of different sub-populations. The National Survey of Sexual Attitudes and Lifestyles (NATSAL) provides data on the characteristics and needs amongst different population groups, including the links between deprivation and sexual health.
Using existing service data
Existing service data provide an insight into the current situation, what may need improving, and where to devote resources.
Comparing the demographic breakdown of service users to the local population will show who is, and is not, accessing local services. We can also look at which groups tend to access which service settings, from specialist services, to GPs, pharmacies and online. This will highlight how people choose to access services.
Some areas have included in their needs assessment a consideration of how people would like to access and interact with services. This can lead to exploration of innovative approaches that ensure services are accessible to a range of populations.
Stage 2: Planning local services and interventions
With increasingly scarce resources, we need to think innovatively about how best to meet population needs. Planning local services and interventions should always start with the patient pathway, with the aim of ensuring people experience integrated, responsive services. It is essential to work with fellow commissioners to map interdependencies and plan to mitigate any risks as early as possible in the process.
Working with both frontline practitioners and the community is crucial at this stage, as it will ensure that the services and interventions you are planning can be effectively and efficiently delivered, are what the population need, and are delivered in a way that meets their needs.
The national specialist sexual health service specification template is an excellent place to start, as this was developed in consultation with commissioner and provider representatives, including the professional bodies. It describes the services any population might expect to have access to and their national standards, and can be amended to reflect local needs.
PHE is often asked ‘What level of service should I commission?’ This should be informed by the local health needs assessment, and there are a number of ways of understanding whether there is sufficient resource to meet the need, such as waiting times and turnaround times for results and treatment.
However, not achieving the necessary standards doesn’t always mean more resource is required. It may instead be about doing things differently, such as a redesign of processes within a service.
As we all know, sexual health services must be free, confidential and open access, regardless of area of residence. Location of services is crucial to ensuring good access. Talking to the local population will inform how and where people want to access services, and highlight unforeseen factors that influence access.
Maintaining good access to sexual health services with limited resources may require looking at different models and delivery mechanisms. For example, models of delivery that involve greater self-management or appropriate use of online services, making sure that those who need to see a healthcare practitioner face to face are able to, and that specialist services have capacity to see those at higher risk as frequently as clinical guidance recommends. These new models of delivery are starting to emerge across the country, but it is still early days.
Speaking to service providers and clinicians
In thinking about changing models of delivery, it is essential to be clear on the purpose of developing a new approach. It is also important that service design is informed by the current evidence base on effectiveness of interventions.
Speaking to service providers and clinicians can be beneficial as they will have invaluable understanding of, and insight into, how to effectively and safely alter the care pathway.
Whatever model of delivery and configuration of services is settled on, it is essential to articulate this clearly – both to those organisations who you will be asking to deliver the interventions, but equally importantly, to the public so they are clear on what to expect.