GUM 48hr ACCESS

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GUM 48hr ACCESS

• Where did the directive come from?
• What are the recommended 10 High Impact
  Changes? (DH/BASHH conference slides)
• What progress is being made in SWAGNET?
• Key interventions for individual clinics
• Questions comments

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UK in Sexual Health crisis

• ? sexual risk taking behaviour
• ? rates of STI, diagnosed undiagnosed
• ? HIV presentations new infections
• ? teenage pregnancies
• ? financial pressures on Trusts/clinics

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• England is currently witnessing a rapid decline
  in its sexual health
• Sexual health services appear ill-equipped to
  deal with the crisis that confronts them
• We call for a target of 48 hours for patients to
  be able to access GUM,
• for the Government urgently to review staffing
  levels
• and for it to ensure that GUM needs are properly
  addressed.

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NHS Operating Framework 2006/7Top priorities -
Selbie 6
Choosing Health 2004/2005
Sexual health and GUM prioritised but PCT
investment did not materialise

• Sexual health and access to GUM
• by 2008 everyone referred to a GUM clinic should
  be able to have an appointment within 48 hours.

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Why Prioritise 48hr GUM Access?
Individual has unprotected sex
Realises something wrong
Tries to make an appointment
Has to wait
Infection spreads
More cases occur
More cases recorded
More difficult to contain
More expensive
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National Review of GUM services National
Support TeamIssues Effecting Delivery general
themes

• Lack of detailed planning to achieve 48 hour
  access target
• Problems with the data IT systems
• No analysis of demand or modelling of patient
  flow
• Role of primary care underdeveloped
• Lack of network development
• Personality and relationship issues
• Financial position difficult. PCTs deferring
  investment .
• PBR pressures driving change to community based
  models in areas which host GUM, but proposals not
  always adequately costed and not always tested re
  patient acceptability and choice
• More scope within existing resources

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1. Measure demand capacity

• This is fundamental to achieving and then
  sustaining 48-hour access
• Measure the demand that is knocking at your
  door
• your capacity may meet average demand - but given
  a choice, patients tend to arrive at the most
  popular times. Identify peaks and troughs

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2. Process Improvement

• Look to optimise patient flow
• Identify bottlenecks and work out which are
  moveable and which are fixed
• Process map to understand the delays and reduce
  patient journey time to improve patient
  experience and release staff time

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3. Multidisciplinary Teams

• In most clinics there is greater scope for using
  the MDT better
• Look at the role of Drs, Nurses, Health Advisors,
  HCAs, and AC staff
• Look at the broader skill-mix across sexual
  health services
• Could your contraceptive MDTs be providing
  testing and treatment for STIs, to avoid some
  unnecessary onward referrals?

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4. Develop low-risk patient pathways

• Focus your pathways on streaming patients - not
  on triage
• Apply major minor principle from AE

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5. Make it easier to access GUM services

• Remove existing barriers
• In principle, a patient should be able to make an
  appointment in one phone call without repeatedly
  redialling or being referred to another service

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6. Reorganise clinic opening hours

• Adapt working times to best suit patient needs
• Ensure this addresses high risk groups, such as
  young people
• Stagger staff hours to provide longer opening
  hours, and avoid setting up the clinic more
  than once/day
• Consider a slot system for walk-in clinics (eg.
  9am 11am 1pm 3pm 5pm 7pm)

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7. Reorganise the physical environment

• As part of looking at the patient pathway,
  consider if any of the physical environment
  hinders access
• Identify any times when clinic space is under
  utilised, and consider adapting clinic times
• If improvements could make a difference, raise
  this with the PCT locally and consider a capital
  bid

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8. Reduce unnecessary clinical activity

• All services have some working practices that are
  based on historical custom and practice
• Look to reduce new to follow up ratios
• National average is now 10.75, (but some are
  achieving 10.5)
• Challenge reasons as to why patients are asked to
  return, and make use of technology
• E.g. Text messages for results allows services to
  abandon unpopular no news is good news policies
• Define and agree what the GUM is there to
  achieve. Stop doing anything that takes you away
  from that goal, and increase aspects that take
  you closer

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9. Assess the readiness of other STI
service providers outside GUM

• Some services are close to readiness
• Look for dual trained staff (contraception/GUM)
  in the community, and unlock existing skills
• Consider Enhanced Services in General Practice
• Ensure GUM acts as a hub dont use this as an
  opportunity to sideline the service because it
  is too expensive
• Look for available PGDs and protocols rather than
  starting from scratch

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10. Make Patient-flow Costs Transparent

• Implement PbR National Tariff if not already in
  place
• Develop clear contracts, defining patient-led
  quality indicators
• Separate GUM HIV costs and activity
• Negotiate cross-charging for GUM patients

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SWAGNET October 2004 Progress Report on Access
Modernisation initiatives undertaken by GUM
services within SWL
South West London HIV GUM Clinical Services
Network
GUM Subgroup Young Persons Subgroup Community
Subgroup Sexual Health Promotion Subgroup IT
Subgroup
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Progress made by SWAGNET Clinics.SIGNPOSTING OF
SERVICES

• Renewed publicity service promotion
• Automated phone systems
• Remove restrictive booking periods (? DNAs)
• Walk-ins accomodated, ? walk-in sessions
• Co-ordinated promotion Point YP Clinics
• Increased collaboration with FP services
• Websites for clinics/SWAGNET

under development www.swish.nhs.uk South West
Information on Sexual Health
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Progress made by SWAGNET Clinics.CLINIC
SESSIONS MODIFIED

• Demand/capacity analysis
• Earlier start/later finish, new sessions
• Modify appointment length/templates to reflect
  changes in clinical practice
• More choice of clinic types

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Progress made by SWAGNET Clinics.PATIENT
PATHWAYS STREAMLINED

• Process mapping, Clinical Governance activity
• Review triage/streaming systems
• Asymptomatic patients modified/separate pathways

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Progress made by SWAGNET Clinics.EFFICIENT USE
OF RESOURCES

• REVIEW STAFF TIME
• Review adjust skill mix to match needs of
  service
• Increase nurse-led initiatives/clinics(limited
  by recruitment/retention)
• Use of proformas, PGDs, shared protocols
• REVIEW CLINICAL PROTOCOLS
• Evidenced based practice rationalisation of
  tests
• Reduced microscopy of male urethral smears
• Female screening for BV, candida, TV
• Reduce unnecessary follow-up
• Is follow-up in person really needed?
• Increased use of home treatments for warts
• Results by Telephone/Text

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Progress made by SWAGNET Clinics.PRIMARY
CARE/COMMUNITY COLLABORATION

• Increased management of GU/STI conditions in
  community may off-load demand on GUM services
• STIF courses
• Chlamydia management guidelines
• Partner notification workshops
• Training of GPs with Specialist Interest
• Community clinics

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Aug 07 85 95 66 97
89 89 85
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SWAGNET EXAMPLES OF MODERNISATION TO IMPROVE GUM
ACCESS

• Queen Marys
• Croydon, Mette Rogers
• St Helier, Yvonne Walker
• St Georges, Richard Lau
• Kingston, Rachel Sands

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TEXTING OF RESULTS

• Unchanged protocol since Aug 2004
• 1. Offer if patient is eligible
• results do not need discussion and are expected
  to be negative (HIV, STS, GC, CT)
• but if symptoms need review or partner
  notification/compliance checked, then followed-up
  by telephone or in person
• 2. Arrange text with patient
• Last HCW to see patient checks mobile, consent
  sticker in notes
• Patient uses laminated slip to book Text Results
• Receptionist gives info slip explaining procedure
  fail-safe
• 3. Results checked, text sent
• Designated receptionist checks that all results
  back against proforma
• Overseen by HA
• Negative results your results are clear you do
  not need to contact the clinic
• Positive results Please contact the clinic on
  020 8487 6861

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Roehampton Clinic RESULTS BY TEXT per quarter
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TEXTING OF RESULTS

• Advantages
• Popular with patients
• Workload can be undertaken at quieter times
• Decreases need for face-to-face or telephone f/u
  (allows more New appts)
• Rapid response to positive results text
• Drawbacks
• Labour intensive, poor automation
• Financial disincentive

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• Tendered to QM by Richmond Twickenham PCT
• 1 early evening per week from early 2008
• Central Richmond. 2 nurses, 1 HA, 1 receptionist
• Walk-in service for 15 asymptomatic patients
• Practicalities / hidden costs. Cost effectiveness
  ?
• Can you target appropriately ?
• Can you regulate demand ?
• SASH model for future STI screening services ?

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SWAGNET EXAMPLES OF MODERNISATION TO IMPROVE GUM
ACCESS

• Croydon, Mette Rogers
• St Helier, Yvonne Walker
• Kingston, Rachel Sands
• St Georges, Richard Lau

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Mayday and 48 hr access

• Dr Mette Rodgers

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• Increase capacity within current resources
• Pan London demand /capacity exercise showed a 40
  disparity at Mayday
• Extending opening hours (shift working)
• Improving access (M and F)
• Limiting appts to later in the day
• Nurse led clinics / PGDs
• Asymptomatic screening
• New fu ratio 10.5

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Asymptomatic screening

• Men
• Women validate self taken vaginal swabs locally
• Increase access and pt flow
• Screening in community / primary care

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Where are we now

• 48 hr access results HPA May 07 53
• HPA Aug 07
  
• In house Aug 07
  70
• Long way to go to get to 100 by April 08
• MedFASHH visit Dec 06
• Monthly meetings with PCT May 07
• Service Improvement Team Aug 07
• National Support team Sept 07

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• Some resources now made available to trust by the
  PCT
• Business case written
• Staff recruitment
• Space issues continue

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National Support Team

• Jane Mezzone - Delivery manager for sexual
  health at DoH
• Nurse consultant Colin Roberts
• Hong Tan (SHA)
• FP lead and manager for Croydon
• Gum / HIV consultant Mayday
• Clinic Manager
• Assistant director of operations Mayday

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• Director of Commissioning for Croydon PCT
• Consultant in public health
• Sexual health lead for Croydon

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• Am PCT
• Pm Trust
• Feedback to both groups together
• Commissioner
• disappointed with lack of use of Choosing health
  allocation 06/07 for Choosing health purposes and
  no reinstatement of full CH allocation 07/08 /
  low levels of GP engagement in provider/commission
  er roles and slow progress with Chlamydia
  screening / shocked that unacceptable rationing
  by PCT re contraception occurred

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• Provider
• pleased with clinic progress on MedFASHH
  recommendations / increase in 48 hr so far and
  local enthusiasm to integrate GUM /FP
• new posts needed asap / self taken swabs / point
  of care HIV testing
• reception vulnerable / data analyst needed /
  further review walk in/appt ratio
• Skill mix of staff / expanded roles esp. of HAs
• Poor premises remain an issue

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• Outside perspective
• Roles based on historical precedent doctors /
  nurses / hca / ha
• teeth
• Non-recurrent financial support
• Fu with the relevant Chief Executives

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Improving Access at St Helier GUM

• Restricted booking of appointments ceased
• Nurse Led clinics instigated
• Telephone Streaming by Receptionists
• Streaming during walk-in sessions

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if no urethral discharge on examination no
microscopy is necessary
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High Impact changes

• Courtyard Clinic
• St. Georges Hospital

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Whats happened since 2004

• 2004
• High risk HIV PTD for HAs
• Telephone results, inc HIV (2005)
• 2005
• Nurse-doctor pairs
• Nurse-led clinics
• Specialist chronic male and female problem
  clinics
• 2006
• Combined MF walk-in queuing system
• More slots for evening clinic
• 2007
• Asymptomatic male Chlamydia GC urine testing
• HIV POC test (limited availability and
  indications)

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What wed like to see

• Texting
• Nurse-doctor pairing (again)
• Better IT
• Faster, more reliable
• Data retrieval for reports and audits
• More capacity for non-invasive tests
• More PbR income coming to GUM(!)