Sexual and reproductive healthcare services lead the way in digital innovation

In this month’s eFeature, Dr Paula Baraitser looks at how sexual and reproductive healthcare services have led the way in NHS digital innovation. Focusing on the pioneering work of SH:24, a not-for-profit online sexual health service, she shares learning from five years of innovation and service development which has delivered online sexual health testing and contraception. Dr Baraitser highlights the importance of online services being a fully integrated part of the sexual health care system and argues that future online innovations in this area will require close collaboration between commissioners, providers of online and clinic-based services and researchers who evaluate the innovations.

Digital cultures have changed the way that people access services. We date, shop, socialise, order food and plan our journeys online. But while our personal lives have been transformed, the NHS is lagging behind. Although 73% of UK citizens have a smartphone, 90% access the internet, 59% of women access health information online, only 2% report any digital engagement with the NHS.

Sexual health is an exception and sexual health services have led the way in NHS digital innovation.

Whereas five years ago online testing for sexually transmitted infections (STI) and online contraceptive services were almost unheard of, online STI testing is now available in most areas of the United Kingdom and online contraception increasingly so. This is something that everyone in the speciality should be proud of - it is a sign of our collective ability to innovate and implement change, increasing access to our services at a time when the resources available to us are reducing. The Faculty of Sexual and Reproductive Health Care (FSRH) and the British Association for Sexual Health and HIV (BASHH) have led the way in being the first professional bodies to issue standards in online service provision in the UK.

What have we done in the last five years?

At SH:24 we have used a four-stage process of human centred design (discover, define, develop, deliver) to prototype and test new online sexual health services including: online sexual health testing; photo-diagnosis and management of genital herpes and warts and online contraception. Alongside these service developments we have created new ways of providing information and new types of clinical conversation. 

What have we learnt in the last five years?

• We have come to understand online services not as stand-alone services, but as an integrated part of the sexual health care system. We now expect service users to move between online services and face-to-face care. For example, someone might order a sexual health screen online and have a positive gonorrhoea result treated in clinic, but have a follow up test online.  These hybrid pathways require close collaboration between services.  It means that the introduction of online services will have implications for clinic workload, often changing the clinic caseload towards more complex care.

• We now have randomised controlled trial evidence to show that online services double access to sexual health testing and that this effect is consistent across age, ethnicity and index of multiple deprivation. We know that there is a similar doubling of access among those who have never tested before. Despite increased access we have found that people using online services screen appropriately.

• We have also learnt that online treatment for simple genital chlamydia infection is highly acceptable and reduces time to treatment. In addition, medical assessment via an online form prior to treatment appears safe1.

• We have learnt about the importance of safeguarding in online consultations with about 8% of young people aged 16-18 reporting a safeguarding issue. We understand that significant clinical resource is required to assess safeguarding issues with effective and appropriate transition to face-to-face care.

• We have learnt that online tests for HIV generate small blood samples allowing laboratories to complete the first test of the three-test HIV algorithm only. All reactive tests from online services will require confirmatory testing in clinic. While negative tests are highly likely to be true negatives, reactive results will have a high false positivity rate and a high proportion will be confirmed negative in clinic. This requires careful communication from the time the test is ordered.

• We have learnt that new remote communication strategies can provide information tailored to clients’ needs and preferences in real time when help is needed. Analysis of 9000 of the text messages received by SH:24 show that people value the simplicity and timeliness of texting for answering both clinical and administrative questions. Our contraceptive discussion forum shows the importance of putting clinical information alongside the experience of ‘others like me’ for better contraceptive decision making.

• Analysis of the first group of users of SH:24s free online contraceptive service showed that online users were significantly more likely to experience short-term continuation of oral contraception compared to participants using face-to-face services. The online group rated their service more highly in terms of convenience, speed of access to oral contraception and ease of communication with provider and had similar levels of basic contraception knowledge compared to those using other services2.

Where next?

We are working on a pre-exposure prophylaxis (PrEP) online service to support those at high risk of HIV to access PrEP remotely and new strategies for contraceptive consultations through webchat. None of these services will be ‘online only’ and collaboration across the whole system of sexual and reproductive healthcare will be needed to deliver them. Collaboration between commissioners, providers of online and clinic-based services and the researchers who evaluate the innovation delivered is likely to be the way forward from here.

I have an ongoing interest in the provision and evaluation of online sexual health services so please do get in touch if you would like to discuss any of the issues raised in this piece further: paula@sh24.org.uk

 

1 - McCulloch H.,   Syred J., Holdsworth G., Howroyd C. Baraitser P.  Online history taking prior to remote prescribing of antibiotics for uncomplicated genital chlamydia trachomatis– testing the safety of three remote communication strategies.  Poster presented at the British Association of Sexual Health and HIV annual conference, Birmingham, 2019

2 - Rezel E.  Evaluation of a Free to Access Online Contraceptive Service in Lambeth and Southwark.  PhD Thesis, King’s College London, 2019

 Originally published in the July 2019 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.