Design and Sexual Health (DaSH)
Overview
The DaSH (Design and Sexual Health) programme was an innovative partnership between Design Options and Gateshead PCT to design a new genito-urinary medicine and sexual health service for Gateshead.
Without its own service, residents of Gateshead had to travel to Newcastle or South Shields to be tested and treated for sexually-transmitted infections. Recognising the problem, the Department of Health provided funding to develop a new service in Gateshead.
Design Options looked at the barriers to using sexual health services, the customer journey and possible ways to improve the customer experience, to create a user-centered service. Many of the recommendations were incorporated into the new service, which opened in July 2008.
Results from its first full year of operation (April 2009 to March 2010) included:
- 3,963 total attendances
- Of these, 55 per cent were new to the service or had a new reason to attend
- 100 per cent were offered an appointment within 48 hours (meeting the government target)
- 99.3 per cent were seen by a professional within 48 hours
- 65 per cent of users attended as a result of a friend’s recommendation
Getting Started
Development of a genito-urinary medicine (GUM) service in Gateshead had been highlighted as a priority, given the area’s population size, pressured services and deprivation levels. Subsequently, £500,000 capital funding via the strategic health authority (SHA) and £500,000 Department of Health (DH) Choosing Health funding, plus time in-kind from Design Options consultancy, was committed to design and implement a new, integrated GUM and sexual health service for Gateshead.
Gateshead Primary Care Trust (PCT) had been achieving considerable success in bringing down teenage pregnancy rates (14 per cent reduction between 1998 and 2008), but it wanted to ensure a new integrated GUM and sexual health clinic built on this success by factoring in findings in the DH’s National Strategy for Sexual Health and HIV. This suggested that users find contraception services to be disjointed from services that offer sexually-transmitted infection (STI) diagnosis or treatment, and that clinics are often held in inaccessible locations that increase feelings of stigma.
Development of the new GUM service became a Designs of the Time ‘07 (Dott07) project. Dott07 was a year-long series of design projects run by the Design Council and the regional development agency One NorthEast, which aimed to explore how design could improve everyday life. Design Options was commissioned to research and design recommendations for a new service that would make sexual health screening and treatment as easy as possible to use. This was done in collaboration with Gateshead PCT and the Centre for Design Research at Northumbria University.
The project aimed to design a user-centered sexual health service that would:
- Operate from a choice of easily accessible venues
- Ensure people are seen within 48 hours of first contact
- Focus services on local needs through effective commissioning
- Integrate services where appropriate
- Improve facilities to decrease the stigma of attending sexual health services
- Ensure effective signposting so that care pathways are completed
The design of the service had to consider a range of policy drivers that were established at the time. In 2004 the Government published its White Paper, Choosing Health: Making Healthy Choices. The paper outlined the Government’s commitment to further transform sexual health services by accelerating implementation of the national screening programme for chlamydia to cover the whole of England and the introduction of a national target to improve fast access to high quality GUM services. Consequently, 10 High Impact Changes for Genitourinary Medicine 48-hour Access (DH, 2006) became an essential reference document for Gateshead PCT in developing the local services. By 2008 every PCT was tasked with ensuring everyone referred to a GUM clinic was offered an appointment within 48 hours, including self-referrals.
A multidisciplinary steering group was set up to provide strategic direction. This was aided by an advisory group, which included representatives from:
- Gateshead PCT (Public Health and Sexual Health Services)
- Newcastle GUM Service
- DH (Sexual Health and HIV, and Children and Young People)
- Family Planning Association
- Regional Teenage Pregnancy Coordinator
- Northumbria University Centre for Design Research
- Southampton University Centre for Sexual Health Research
- Consultant physician
Scoping
The overall aim of the project was to provide a user-centric GUM service in Gateshead so that local residents would no longer need to travel to Newcastle or South Shields for sexual health services. As there was no existing service, it was impossible to establish a baseline for service provision and identify increased usage, so the behavioural goal was simply for residents to use the new service.
While the proposed service would respond to the needs of all users in Gateshead, Design Options was asked to consider a segmentation of priority (high risk) users of sexual health services based on the NICE guidelines on one-to-one interventions with vulnerable and at-risk groups. These priority high risk users included young people, men who have sex with men (MSM), looked after children, and sex workers.
To ensure the service would meet the needs of users, it was essential to involve the people of Gateshead in an extensive consultation process. To understand how people feel about accessing such services, the Design Options team consulted approximately 1,200 health and community professionals and members of the public in the Gateshead area.
Scoping methods
- Visual mapping – The Gateshead area was mapped to discover key infrastructure, health services, transport links, etc.
- Provider meetings and workshops – Working groups consisting of local PCT staff, a steering group and advisory board of experts had regular meetings
- Stakeholder mapping – Mapping of local and national stakeholders who were informed and consulted throughout the project
- Clinic visits – Clinics were visited locally and nationally to draw inspiration from best practice
- Street interviews – 500 Gateshead residents were interviewed in locations throughout the district
- Questionnaire and vox pops – Distributed to health and community centres to capture the opinions of local residents about sexual health services
- Cultural probes – Booklets and packs of tools were given to Gateshead residents to capture rich information about their lives – through writing, drawing and taking photos
- One-to-one interviews – Professionals from local organisations were interviewed to find out what they felt was important for the new service
- Service user workshops – Interactive workshops were held with different community groups
- Care journey mapping – The ideal experiences of sexual health services were explored through ‘personas’
Persona and scenario creation
The process of researching sexual health needs is complicated by the stigma attached to the issue. For instance, few users would be willing to come forward and say they are homosexual and suffering from syphilis. To overcome this and create a patient voice where there potentially was none, the Design Options team used the findings from the cultural probes to create 12 ‘personas’ – descriptions of fictional people living in Gateshead, each telling a story about how they came to need a sexual health service and what their experience was like. These personas were then pretested with existing service users, as well as health professionals, to check the research findings. This ‘softer’ evidence provided a useful support for the harder evidence captured through more quantitative research methodologies.
Insights
This research revealed a range of insights related to using sexual health services:
- Stigma and embarrassment still surround sexual health issues and prevent people from accessing services or seeking advice
- Inconvenience of existing services prevents frequent use – they were not available locally, not accessible in the evenings and weekends, and not discreet or private to use
- Young people in particular are reluctant to go to a family GP with sexual health-related issues
- There is a lack of ability to recognise symptoms that might be a sign of STI and the perception that if the symptoms go away the disease has too
- Use of condoms is still not considered essential if other contraception is being used
- There is a lack of knowledge about how common STIs are, how easily an infection can be transmitted and how easily they can be treated
Key barriers to using a sexual health service include:
- Awkward to get to the service
- Embarrassing to be seen in a ‘clap clinic’
- The clinical environment puts young people off
- Standing in reception and explaining why you are visiting is daunting
- Although people know regular check-ups are beneficial, filling in the same form each time is annoying
- Fear of the unknown puts people off
- Worry that having to make an appointment by phone means having to explain the issue out loud
- Going to the clinic by yourself is off-putting, going with a friend or partner would be helpful
- A belief that ‘I’m not ill, so why should I go?’
These insights were used to guide the service redesign proposals, so that barriers to using a service could be minimised and benefits maximised.
Competition
The research established sources of competition for a new Gateshead service. The main source of competition was the existing Newcastle GUM service that users already went to. While the Gateshead service offered to relieve pressure on the Newcastle clinic, its development also had important funding implications for Newcastle, as funding allocations are based on attendance figures. To ensure coordination and communication between the two services, members of the Newcastle GUM service sat on the steering group for the DASH project and fed into its development.
Because Gateshead never had a GUM service, it had a very well developed community contraception service, which had good links within some of the hardest-to-reach communities and was reaching young men effectively. To avoid two services competing, the community contraception service would become part of the new integrated Gateshead GUM and sexual health service.
Development
The recommendations proposed by Design Options covered six key areas: core service structure; service promotion and awareness raising; service gateways; clinic overview; user flow through the clinic; and actual clinic environments. Below are some of the key recommendations made:
Core service structure
Originally, Gateshead PCT had to deliver sexual health services over a large area, with relatively poor transport links. High quality outreach work was already being carried out by Gateshead PCT, and these two factors formed the basis of the proposed new service, which would provide a central integrated GUM and sexual health clinic, supported by local or satellite sexual health services:
- This hub and satellite model for service delivery should be supported by increased laboratory capacity via a mobile laboratory
- Walk-in sessions should be available at the hub and satellite location throughout the week
- Extended opening hours twice a week (evening sessions) and Saturday sessions should be available
- Walk-in sessions should be recommended to users to meet the target of seeing them within 48 hours of an appointment request
- The majority of sessions should not be themed or restricted to any particular group of users, with the exception of two single sex walk-in sessions
Service promotion and awareness raising
- A tailored branding and publicity campaign should be run to promote the service to different audience segments (including posters, fliers, bus ads and adshels)
- Sub-brands and dedicated services should be developed for discrete sub-groups, such as MSM, older service users, asylum seekers and refugees, sex workers and their clients, ethnic minority communities, people with mental health problems, people with drug and alcohol misuse problems, people with learning and/or physical difficulties, gypsies and travellers
- Local television and radio broadcasts should be made, as well as links to the site from different service portals
- Take-away materials, such as flyers, leaflets and wallet size cards, should be distributed in public areas
- Health promotion presentations in schools and colleges should be delivered by School Nurses and members of the Sexual Health Promotion Team
Service gateways
- A strong website should be developed, with online booking facilities
- A single freephone number should be the main portal for the telephone contact for the hub and satellite clinics
- Test results via text messaging should be offered
Clinic overview
- The sexual health hub/clinic should be located in central Gateshead with good connections to local transport
User flow through the clinic
- Ideally a service user should never have to ‘retrace their steps’ during their visit – for example, service users should not be requested to return to the waiting room to wait for results
- Service users should pass through the stages: arrival and greeting; registration; waiting; consultation; examination (including urine collection); waiting for results; exit; and re-booking if needed. The clinic space should be designed in such a way that the service user moves consecutively through spaces with clear and defined functions
Clinic environment
- The interior of the hub/clinic, and where possible satellite clinics, should be non-clinical, similar to the style of a hair salon or cafe
- Soft furnishing should be used where possible
- Colour and/or numbers should be used in different rooms to aid the feeling of progression through the service
From the service user’s perspective, the physical integration of sexual health services with related services in a ‘one stop shop’ model would encourage a more holistic view of health and wellbeing, in addition to making access to sexual health and related services more convenient. The service in Gateshead would offer GUM and sexual health services, including family planning, contraception and abortion support, psycho-sexual counselling and links to ongoing regional work on gender dysphoria.
The blueprint for the new service was sent to over 100 professionals locally and nationally with invitation to comment.
Implementation
The recommendations made by Design Options were presented to Gateshead PCT at a roundtable discussion to decide which to take forward and how to proceed. Using these recommendations and research, the sexual health services responded to the submission for tenders from Gateshead PCT to run an integrated GUM and sexual health clinic, and were successful in their bid.
The business case was established in December 2007. Initially the PCT wanted the service to open in April 2008. However, due to the restructuring of PCTs and the need to convert premises to house the sexual health service, this was pushed back to July 2008. This extension allowed key staff to be trained before the service was launched.
While the service was recommended to be located in central Gateshead, due to costs and the availability of premises, a strategic decision was made to house the new clinic/hub at the Bensham Hospital, with satellite services initially at Bede, with more satellite services in other locations to be added later.
During the development of the new clinic at Bensham Hospital, the sexual health services team came up against obstacles to implementing some of the recommendations proposed. For instance, they were unable to structure the service so that users would never have to ‘retrace their steps’, and they were unable to use interior colours to aid the feeling that patients were progressing through the services, due to NHS guidelines.
“At the time the project was being implemented there were strong NHS branding principles so this meant that we weren’t able to deliver on some of the themes/colours, etc. This meant the colours of the rooms and beds were pre-chosen, but we were able to break up the area by using curtains as screens for the couches and other clinical equipment.” (Angela Star, Assistant Lead Sexual Health Services)
Despite these minor issues, some key recommendations were implemented in the structure of the new clinic. One success was the layout of waiting rooms to make them more discreet, as the research had highlighted that the usual layout of waiting rooms with chairs in rows put people off using the services.
“We were able to influence the waiting area for example. Traditional NHS waiting areas have everybody sat in a row, and one of the things that the team came out with is that wasn’t what people wanted to do. They wanted to sit and be discreet and not having to sit and face somebody because they’re sat in a row. So we now have single seating around small tables and TVs in the waiting area, giving users the feeling of personal space.” (Angela Star, Assistant Lead Sexual Health Services)
Work undertaken locally by a public health analyst was used to guide capacity forecasts for the Gateshead service, based on attendance figures at the GUM service in Newcastle (one-third of its service users coming from Gateshead at the time). Based on these figures it was decided that a staged approach should initially be followed, so that demand would grow only at a rate that the service could support.
Subsequently, while the doors to the new service were opened to the public in July 2008, it was decided that promotional advertising would not begin until the service had established itself. The first round of promotional advertising was launched in October 2008. This campaign was targeted at young people and was entitled ‘Love or Lust, a check up’s a must’. By contrast, marketing to MSM service users was carried out via word-of-mouth, using existing service user groups and trusted networks to promote the new service.
Since this campaign, the marketing plan has been refreshed and the media materials are currently being drawn up to include themed leaflets, condom holders bearing the freephone number, posters and advertising on the Metro system, which runs across North and South Tyneside. Facebook and website advertising is also run about the service.
Evaluation
The new service is evaluated closely against the DH’s Service Specification Performance targets, and provides monthly and quarterly reporting on activity to the DH.
In its first full year of operation (April to March 2010), performance figures included:
- 3,963 attendances, which has increased steadily since the service has been opened
- Of these, 2,160 (55 per cent) were first attendances or had a new reason to attend
- 100 per cent of users were offered a clinic within 48 hours, meeting the government target. The service runs as a drop–in, so appointments are not routinely used
- 99.3 per cent of those offered a clinic were seen by a professional within 48 hours
- The majority of users opted to receive their results via SMS
- The ‘Did Not Attend’ rate was relatively low at 8.8 per cent, and the majority of these were from follow-up patients
- 65 per cent attended as a result of a friend’s recommendation – an encouraging figure for the promotion of word-of-mouth publicity as a key means of encouraging protective sexual health behaviours
The service has had some excellent feedback from users, which reflects the hard work of the team. Quotes from a patient involvement exercise in June 2010 include:
“[The nurse] was very helpful and polite all the way through my visit, thank you.”
“All receptionists were very friendly and helpful, and the nurse was wonderful.”
“No waiting, was seen quickly, no problems.”
“The staff that I was examined by were very helpful. They went out of their way to put me at ease and explained everything to me that I needed to know.”
Follow Up
Once the new integrated GUM sexual health service opened, a follow-up and feedback session was held at the Baltic Centre for Contemporary Art in Gateshead. The meeting provided the forum to discuss lessons learned during the set up of the new service and how additional recommendations made by Design Options could be integrated into the further development and implementation of the service.
The original research and recommendations were disseminated widely by the Dott07 programme through publications, conferences and website case studies. Gateshead PCT has shared learning with a variety of organisations that have approached it to find out about how these proposals were implemented in practice and what obstacles were faced in delivering the recommendations.
Lessons learned
Engage with other services that have the skills to conduct any consultation necessary. Having Design Options conduct the consultation and research brought much added value that could not have been achieved in-house. Design Options brought a wealth of experience in particular around engaging with the communities and professionals, using methods the sexual health teams had never used before. This provided great insight into what the public and other health colleagues wanted from a new service.
Involve the communications team in your project from the start so that any communications and marketing materials are developed with in-depth understanding of the research results.
“I think we probably should have had someone from the Communications Team right from the start of the project, so they could be on the journey with us and not just coming in when we needed to develop some marketing or starting to disseminate the information. Understanding the way a sexual health service runs is key and the Communications Team we have now have a wealth of experience we draw on to ensure the right messages are getting to the right people.” (Angela Star, Assistant Lead Sexual Health Services)
A staged approach to delivery was crucial. The new service went live in July 2008. For the first two months, it was only advertised within the health economy (primary care and sister services). A higher profile public advertising campaign then began in October 2008 to raise awareness amongst potential users. This ensured that users were only directed to the service once it was up and running and ready to cope with increased demand.
Be prepared for the unexpected – implementation of the new design recommendations was held up for several months by restructuring of the PCTs and the search for suitable premises to be used or adapted to house the new service. This meant that although the business case was approved in December 2007 with the aim of going live in April 2008, the service did not actually open until July 2008.
