Restrictions imposed by COVID-19 on clinic-based sexual health and reproductive health services have accelerated the scaling up of digital and remote care options to maintain access to vital services during this period. SH:24, a digital sexual and reproductive health service commissioned across several areas of the UK, has been at the forefront of this digital expansion. In this eFeature, its Managing Director, Dr Gillian Holdsworth and colleague Dr Ahimza Thirunavukarasu share their experience of scaling up at speed, managing additional demand and bringing forward new service areas.
Looking back over the past few months, it is striking how swiftly our lives can change. The surge in COVID-19 cases during March delivered a shock to an already stretched healthcare system. Many face-to-face services closed or operated limited services and staff were deployed from all specialties, including sexual and reproductive health (SRH), to support the NHS response.
The journey made by SH:24
SH:24 also needed to make rapid changes. Within 24 hours of the Government announcing restrictions, we had to set up remote working arrangements for our London office staff and quickly implement physical distancing guidance in our Keele logistics site, from where we send out test kits. There was little time to settle into these new ways of working before we were asked to scale up our operations. In response to the suspension of many clinic services, existing commissioners of SH:24 sought to maintain service continuity by requesting changes to our offer in their areas: for example, removing daily caps on the number of STI tests that can be ordered, and making new services available to their residents. In addition to this, thirteen new areas started commissioning SH:24 services between the end of February 2020 and June 2020.
Here are some of the additional key changes we made to our services:
We were requested to expand chlamydia treatment prescribing to include uncomplicated symptomatic chlamydia, rectal chlamydia and treatment for people aged 16 -17 years old.
We brought forward the launch of our emergency contraception service to the end of March.
In response to concerns that young people were being disadvantaged, we changed the age eligibility for oral contraceptives to include people aged 16 - 17 years old, with safeguarding measures put in place.
Photodiagnosis was commissioned as a service (previously piloted).
Public Health England (PHE) requested us to provide a National HIV and Syphilis testing campaign to “Break the Chain” of infection. We developed an online HIV testing pathway for PrEP Impact Trial participants, in collaboration with PHE, to maintain access to the trial for participants in regions without online testing.
The volume of orders for SH:24 STI test kits, chlamydia treatment and oral contraception increased significantly in line with these changes to our service and the wider COVID-19 context. STI test kit monthly orders rose from 23,721 in April to 30,031 in May, increasing to 41,633 in June. Monthly chlamydia treatment orders steadily increased from 654 in Feb to 1147 in June and monthly oral contraception orders more than doubled from 500 in February to 1203 in March, reaching 2814 orders in June.
To cope with this additional demand, SH:24 had to make swift changes in how we operated. New areas were mobilised entirely remotely, in lieu of a series of visits to train clinic staff in the digital service. Our clinical team had to manage the increased activity and ensure that they met the most urgent requests promptly. Our service development team worked to improve the efficiency of the clinical team’s processes and ensure that COVID-19 related changes were prioritised. The resilience of our supply chain was tested and the logistics workflows were optimised to ensure that the timeliness and quality of our service was not compromised.
Reflecting on the journey
At this juncture, it is important to reflect on these changes that were, by necessity, made on an accelerated timeline.
This has been a challenging time for everyone. Initially, increased workload had to be managed by our existing staff, and while SH:24 has increased staff numbers to help with the COVID-19 response, most of us have been working at full capacity. More conscious effort and time has been required for cross-team collaboration, which has been achieved using a range of digital platforms.
Meanwhile, staff have also had to juggle pressures of the job with new and different personal stressors and the poor delineation between work and home time. Learning to support staff wellbeing from afar has been a steep learning curve. Nonetheless, the merging of boundaries has led to a closer and more compassionate team spirit, and the realisation that we can all work effectively from home has been reassuring.
Throughout this period, we worked closely with commissioners and local service providers to be responsive to their needs. Many of the adaptations we made were either complementary to existing service or had been prepared for launch prior to the pandemic, and therefore could be scaled up at speed. We have continued to innovate, improve and expand our service, ensuring patient safety and quality of care throughout. Having clinical staff who work in both SH:24 and face-to-face clinics plugged us into the ‘real-world’ issues taking place and helped us be more sensitive to our NHS colleagues’ experiences.
We intend to evaluate the effects of these changes, beyond the increased volumes, in terms of other important metrics such as equity, efficacy, acceptability, appropriateness and staff wellbeing.
Where does this leave us?
As highlighted in our Clinical Director Dr Paula Baraitser’s eFeature last year, the SRH sector has been leading the way in its embrace of digital services and innovation. We entered this difficult period with this advantage, and the early recommendations from the British Association for Sexual Health and HIV (BASHH) and the Faculty of Sexual & Reproductive Healthcare (FSRH) demonstrated the trust in digital services’ capacity to deliver good quality, frontline care. This has also been reflected in the recent call from PHE for a national eSRH framework. At SH:24, we hope that we have shown that digital expansion can be done thoughtfully, collaboratively and safely.
We are also conscious of the disadvantages, particularly the disproportionate cuts to funding, with which SRH services were dropped into this pandemic. While we, at SH:24, are proud that we were able to step up to the challenge, we know that digital services will only ever be a part of the system’s solution. Face-to-face service provision for people experiencing vulnerable circumstances, complex problems or structural barriers must continue, as set out in BASHH’s Principles of Recovery.
Now, more than ever, as people begin moving between digital and face-to-face services, we should all be working closely together to provide smooth, holistic SRH care. We hope that our experience in providing a clinician-led digital services can support this, and that we can all take forward lessons from this pandemic to shape a better future.
SH:24 is a digital, user-centred sexual and reproductive health service, commissioned by several areas across the UK. The development of the service used an agile design led approach and SH:24 has a strong focus on the promotion of self-care. Services available through SH:24 include STI testing, chlamydia treatment, oral contraception and emergency hormonal contraception, photodiagnosis and treatment of genital warts and herpes.
Published in the July 2020 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin. The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.