Dorset Council has got its providers working collaboratively, resulting in less fragmentation, improved services for patients and greater emphasis on prevention. This case study forms part of our sexual health resource.
Historically in Dorset there were four different contractual arrangements for the provision of sexual health services – one for the community, two to run Genito Urinary Medicine (GUM) clinics and a fourth for the online offer. The services were run separately and so were fragmented in delivery.
On average about a quarter of service-users accessed GUM services for simple checks and advice, which could have been delivered more effectively and efficiently elsewhere.
During 2014/15 Dorset started to look at ways of integrating services, including approaches to tendering as well as using a section 75 agreement with Dorset CCG, which became less feasible when NHS England decided to retain responsibility for commissioning HIV services.
So Dorset had to consider different approaches to meet the challenges of the national public health grant reduction.
The council saw this as an opportunity to change its approach. A block contract was introduced in 2015/16, replacing the payment by results system that had been operating until then.
The contract was structured so that savings of 20 per cent were phased in over three years and the council worked with the providers to look at how services could be restructured to tackle service changes and meet the national budget expectations.
A memorandum of understanding was signed between all the providers to work together to integrate services and make financial reductions where required through innovation.
The community provider, Dorset Healthcare, was appointed lead provider with full support from the other providers and since then the system has worked together successfully sharing decisions on changes that they needed.
Assistant Director for Public Health Sophia Callaghan said: “Services seemed fragmented – the services were split across the east and west with often variation in capacity for the rural and conurbation areas that could be better designed to meet demand. We felt improvements could be made under the principles of efficiency, effectiveness and value.
“The move to block payments helped us to manage financial risk and gave providers the opportunity to work more flexibly to innovate and change within their services. What is more, payment by results created a ‘test and treatment’ focus, as opposed to an outcomes focus which was more geared up on prevention.”
By the end of 2018 significant changes with the way services were organised began to transform the system. Previously there were 13 small clinics dotted across Dorset housing different teams and services. Instead these have now been amalgamated to four larger integrated clinics where staff from the different services work side-by-side.
These clinics operate as spokes to one main hub in Bournemouth and satellite hub in Weymouth. As part of these changes, a greater emphasis has been placed on prevention with healthcare assistants (HCAs) trained to encourage behaviour change.
Helen Martin, the Service Manager at Bournemouth, said: “Our healthcare advisers are key to encouraging behavioural change. HCAs run independent asymptomatic male and female clinics and within the assessment they can identify patients whose behaviours put them at risk in terms of smoking, alcohol, risky sexual behaviour and contraception.
“The HCAs are able to advise, onward direct and signpost these patients where they can seek further intervention. For patients who present in these clinics with a number of risky behaviours or more complex issues they are then referred to our health advisers at this clinic appointment and seen on the same day.”
There is also a more flexible and responsive outreach service that provides support to those more vulnerable groups that may engage in risky behaviours.
Ms Callaghan said: “The integrated set up is easier and more accessible for patients. The clinics are essentially one-stop shops where patients can access a more comprehensive range of services and can be properly triaged so they receive the right support the first time.
“One example is the Over the Rainbow, a gay men’s health promotion service. That used to be run from one building in Bournemouth, has now moved from the building to a virtual service, which is now available across the county via the clinics. It means it is much more accessible to people over the whole county.”
The working culture is also vastly different with staff now supporting different sites. “We’ve been able to tackle some of the demand issues in higher need areas and we are much more flexible. The service is essentially one – not fragmented as it once was,” added Ms Callaghan.
The council worked with the providers, helping them to assess and review new ways of working. A series of task groups was set up. These covered topics such as needs based service modelling, clinic design, pathway development, prioritising prevention and online and IT development.
Initially groups were council led – to outline expectations – but soon moved to providers running planning themselves, sharing expertise and decision making.
Ms Callaghan said: “The key was that it was not prescriptive, but provider led. It was a collaborative effort. Providers know how services work and how to get the most out of them so we let them design things and supported them along the way. I think that is a key bit of learning – letting go and building trusting relationships for providers to deliver.”
Jane Cromarty, the Clinical Practice Practitioner for Dorset Healthcare, is full of praise for the approach. “The process of integrating sexual health services in Dorset has enabled the people most knowledgeable, committed and passionate about ensuring high quality reproductive and sexual health for the local population to collaborate and develop a new and innovative patient-centred service.
“The teams have worked tirelessly, in addition to their usual workload, to deliver a large scale project within a tight time frame.”
How is the approach being sustained?
Now the new clinics are establishing, Dorset is looking to the future. It aims to build and expand on the online testing services and use of social media
Once premises are available the Bournemouth hub will move out of hospital where it is currently housed and into an integrated community venue.
Meanwhile, the outreach team is in the process of developing its model with a focus on prevention and education, working with the highest-risk populations and schools by supporting them to prepare for the introduction of compulsory relationships and sex education.
Ms Callaghan said: “We are really happy with the progress made with service development and future direction. There are good relationships across the system and that is helping us improve services and innovate. “One of the next things we are thinking of exploring is whether there is benefit in bringing the LARC service run by GPs and the emergency contraception service provided by pharmacies into the integrated system as a pan-Dorset model.”
Sophia Callaghan Assistant
Director for Public Health Dorset Council