About a year ago the UK’s government watchdog, the National Audit Office, wrote a damning report about the state of the National Health Service’s finances, warning that the gross deficit of NHS and foundation trusts had increased by 150%.
The report found that the Department of Health had issued £1.8 billion in cash injections to 46 NHS bodies since 2006, with only £160 million having been repaid.
Over the past few years the NHS has been going through a complicated restructure, with budgetary powers being shifted from some groups towards others - if you’d like a detailed overview, take a look at this BBC article - however, despite this, the fact remains that the traditional provision of health services is extremely costly.
This is putting a huge strain on local authorities and clinical commissioning groups (CCGs).
In my view, the answer to this problem, if we want to retain free healthcare at the point of service, is a huge rethinking in the way that health services are traditionally delivered. And whilst the government and NHS England is talking a lot about big digitisation projects and back-office IT, we also need to be thinking about how client-facing services can be integrated with digital tools.
And we need to be thinking about this now. Service redesign and online scale could really help save health services and allow them to refocus their finances on critical face-to-face requirements.
Which is why when I was pointed to SH:24, operating out of the Lambeth and Southwark boroughs in London, I was keen to find out more. SH:24 - a free online sexual health testing service - is a good example of how digital tools can be used to not only cut down on costs, but also actually provide a better frontline service.
The organisation, a community interest company, provides free and confidential STI testing for residents of Lambeth and Southwark, where its users can order home testing kits over the web for Chlamydia, Gonorrhoea, Syphilis and HIV.
Kits are sent out via freepost and results are issued via text message within seven days (although it’s often more like 3 days). All of it is completely confidential and the organisation also operates free sexual health advice via text message and web chat.
If someone is diagnosed with an infection and requires treatment, they are then fast tracked into the required NHS service locally.
For the user of the service it’s free, it’s easy, it’s efficient and it’s discreet. For the NHS it removes all those first points of contact that take up time and resources that could be put towards treatment and counselling.
I visited SH:24’s offices at the end of last week to find out more about how this service came about and how it plans to scale up. When entering SH:24 it’s obvious that they’re operating with a digital-first mentality. There are posters and post-it notes stuck up all over the walls, with colourful agile diagrams and flows being used everywhere, with the idea of ‘design’ being central.
The company is being headed up by public health medicine consultant Gillian Holdsworth and service development director Chris Howroyd. It’s evident from the meeting that SH:24 has tried its best to bring the world’s of health and digital together, both in terms of delivery and it’s skill set.
Unfortunately Howroyd wasn’t there on the day of my meet, but Gillian Holdsworth explained how SH:24
came to life. She said:
I was aware that we had the worst sexual health in the country in this area. The other thing I was also aware of is that it’s not always very easy to access those services. People come into London, don’t have a GP, can’t take time off work. We don’t make services easy for people to access to be honest. So one of my trainees said to me why don’t you put STI testing online? I thought about it and thought, why don’t we put the whole lot online?
We are still delivering services the way that we were in the 1960s and 1970s. In 2009 we did the first expression of interest interest to the Guy’s and St. Thomas’ Charity, which funds a lot of innovation in Lambeth and Southwark.
What we were doing was trying to disrupt a service, pick it up and move it online. A bit like Amazon did.
SH:24’s development continues to be funded by Guy’s and St Thomas’ Charity, but it’s operations are funded by winning contracts with local authorities and CCGs (the NHS) - as the service is commissioned by these two groups. This is what makes things slightly tricky for the organisation to scale up outside of Lambeth and Southwark, the fact that it can’t go to one organisation and say ‘we can provide this service to the whole of the UK, provide it better and provide it at a cheaper price point’.
SH:24 has to bid for each contract with each local authority and each CCG, depending on which organisation is providing what services. For example, in Lambeth and Southwark STI testing is paid for mostly by the local authorities, whilst oral contraception is about a 50% split between local authorities and CCGs. But this varies across the UK, which makes funding and scale challenging.
However, it has just been announced that SH:24 will now be expanding to Essex too. Holdsworth said:
When we were writing up the proposal and conceptualising the service, my clinical colleagues and myself believed really, really passionately that this isn’t a service that should just be for Lambeth and Southwark people, but everybody should have access to some sort of online sex and reproductive health service. The current system doesn’t make sense. We built it to scale and so we hope that within five years that everyone will have access to our service or something similar.
To be honest, it’s such an obvious business model. It’s a bit of a no-brainer. We have done a lot of stuff around the country and people keep talking about how it’s really radical and we are using these new technologies - but mobile phones came out years ago. It’s not that modern.
They think modernising their GU service is taking it out of the hospital and putting it downtown and creating a website where you can find where the services are and what the opening times are. They aren’t very modern in their thinking.
Holdsworth explained that the development of the SH:24 service has been split into a number of phases, which reflects the agile approach in its delivery. For example, the first phase was putting testing for STIs online. The second phase was around user support, which allows people to text, web chat or request a call back. The next phase of the project starts at the beginning of next year and will involve putting chlamydia treatment and emergency contraception online. By the Summer 2016, all contraception will be online. Holdsworth said:
We’ve worked really, really closely with our local specialist sexual health providers. And in the event that anyone tests positive, they get fast tracked into local services so that they don’t have to queue. They get all their results by text message and if they get a reactive HIV result, they get a call from a clinician, which is exactly the same if they tested positive in a clinic. And then they would be invited to go in and again be fast tracked.
Users really like it, it’s incredibly convenient for them, they really like the support they get, commissioners like it because it costs less than half the price of walking in through a clinic. Clinics are overwhelmed. They are turning people away. To be running clinics in that way where people are being turned away and left in tears and not being able to support people in those situations, it’s quite upsetting really.
The clinics advertise us. They’ve got windows plastered with enormous adverts.
However, SH:24 also recognises that this isn’t just about redesign of digital services, but the redesign of offline interactions as well. It believes that around 75% of its service provision is actually carried out offline. For example, I was shown a kit that it sends out to clients and was shown a kit that is used by the NHS and the difference is startling.
Thought has been put into everything from the way that the information is portrayed to the user, through to the packaging.
But I was keen to find out if Holdsworth believes that SH:24’s model can be applied to other elements of health and social care provision. The reason being that I often hear locally that digital is less relevant to this area of local services and couldn’t make much impact. But by looking at SH:24’s operation, it’s obvious that this just isn’t the case. Holdsworth said:
I think that the answer to that is yes [it can be applied elsewhere]. It’s not just about information, it’s about allowing people to test at home. I think that what we have shown is that people can give you a blood sample from home. What you have going forward is the ability to not just provide information through a web-based service, but there is also something about being able to get the diagnosis so that you can then start referring people into the right bit of the system.
The other thing is that when we started doing this, GPs said that none of their patients would use this service because they like going to them. That may well be true, but actually quite a lot of people will use a service like this because when you phone up and you can’t get an appointment with your GP for 10 days you will look for some other option.
This is a great example of how a community interest company has figured out, to a great extent, how to
better deliver an element of health service provision using digital tools. The problem is that NHS and local government complexity means that scaling this up isn’t going to be easy. And that’s not a technology problem, it’s a case of having to work with and apply for funding from each and every local authority and CCG.
However, if you’re in any doubt about the benefit to users, take a look at some of these quotes:
It's ironic that though it's a remote service, it's more personal
Received my @sh24_nhs results today only 4 days after I sent the specimens off. Dead impressed, definitely using the service again!
That’s brilliant – an amazing service! Well done to all concerned, this will make a lot of people very happy, it will change some people’s lives!
This has renewed my faith in the NHS…turns out it can offer decent services online… why can you do it so well for this, and so badly, or not at all, for everything else?
Everyone in the UK should have access to this service, it’s common sense
More of this please.