London’s Sexual Health Transformation Programme provides valuable lessons for any organisation collaborating to deliver system-wide change. Mary Cleary, Programme Lead, and Dr Andrew Howe, Director of Public Health for the London Boroughs of Harrow and Barnet, describe their approach.
When responsibility for sexual health transferred from the NHS to local government in April 2013, commissioners in London realised there was a case for changing the way we ran sexual health services.
Demand was increasing exponentially, resources were getting tighter, access varied across the city, and patients were travelling away from home to get advice. We also needed to rethink how to protect open access.
In the first two years, collaborative working delivered strong results for several boroughs, including better cost management and standardisation of KPIs and clinical specifications. The success of these small projects gave commissioners confidence in what could be achieved through greater collaboration, leading to the creation of the London Sexual Health Transformation Programme in December 2014.
Governance was kept simple, balancing pan-London decision-making with local structures. It was led by a director of public health and a core group of six to eight, with a programme lead brought in to coordinate and drive progress. A council chief executive chaired a programme board with representation from all 32 boroughs.
The first task was to talk with commissioners, providers, potential providers and patients to see what worked and what needed to change. Clinical workshops, commissioner events, waiting room surveys, focus groups, online surveys, market events and private meetings tested the appetite for change and explored opportunities. From this, three work streams emerged.
First, it was agreed to offer an online option for people to get advice, testing and diagnosis. Over half of those who attended clinics did not report any symptoms and just wanted a check-up. Many told researchers they would be happy to access services online. This would free up clinic time for the more complex cases and help promote prevention and public health.
Many of those who attended clinics told researchers they would be happy to access services online
Providers, commissioners, patients and other stakeholders worked together to develop a vision of an online service to allow patients to receive advice, and if clinically appropriate receive testing kits through the post or to collect from a clinic or pharmacy.
In parallel with this work stream, the programme recognised that there was a need for a London-wide service specification to ensure that services aligned with the new e-services; just adding a new option would not bring about whole system change. A clinical group developed a specification for integrated sexual health services which is now being used across London.
Third, work started to develop an integrated tariff; this allows providers to be paid fairly while enabling commissioners to improve planning by developing a detailed understanding of which services are being used.
What has been achieved?
Negotiations are continuing with potential providers for the new e-service, and the successful provider will go live in May. Boroughs are procuring complementary local services. A company specialising in behavioural change has been appointed to support both staff and service users in making the channel shift from clinic attendance to online. Every borough has adopted the integrated tariff.
What lessons can be learned from the programme?
Partnership is key – this programme would not have made progress if boroughs had chosen to work alone. Partnership has risks and challenges but it is the only way to bring about change of this scale.
Start small and build – partnerships can be developed through small initiatives, building capacity and confidence to take on bigger challenges.
Find the right balance between local and regional control – a regional approach creates efficiencies and pools ideas and opportunities, but it is important to respect local political agendas and decision-making. The sub regional model has worked well, with locally-based collaborations driving progress relevant to their boroughs.
Detailed work makes a difference – the work on specifications and integrated tariff required boroughs to work together on the detail, developing a shared understanding of problems and solutions.
Nothing works without generating buy-in from all stakeholders – collaboration only works if people see the benefit and choose to opt in. There are legitimately differing agendas, but they can be managed to mutual benefit. And buy-in has to be continuous; just because people were supportive does not mean they will continue to be.
Risk has to be recognised, acknowledged and managed – risk register must be a dynamic document that requires constant discussions and re-assessment and frames debate.
It is not always possible to do things perfectly – ideally the programme would have developed multiple pilots, but there was not enough time or money. So lessons were learned from some existing schemes such as Greenwich CheckURSelf and national chlamydia screening
Working with markets is still new for some areas in the public sector, but it is essential – the two Prior Information Notices that the programme has issued, followed by interviews and meetings with a wide range of providers, have challenged thinking and taught invaluable lessons.
Continual engagement with as many segmented audience groups as is possible must be at the centre of the programme – a positive loop of ideas, feedback and challenge helps nuance ideas and surfaces problems and opportunities. The programme team were always willing to hear and change; they committed to an open dialogue with all interested parties and made sure people had their say.
Keep going – change programmes inevitably go through periods of conflict, when it is easy to get side-tracked. Keep focused on the vision and drive progress where you can.
Three pillars provided the foundations for the programme and allowed progress to be made:
- A strong collection of forces recognising the need and pushing change
- Transformational leadership; this is not about imposing solutions, but communicating a vision and then facilitating a system that allows and encourages everyone to work together – provider, political, community
- A robust and constantly evolving governance system.
The London Sexual Health Transformation Programme has achieved a lot in a short space of time. However, the true test will be in six to nine months when the e-service is running, the sub regional procurements are concluded and patients are making their choices. Only then will it be possible to know if the change has worked for our communities.