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What initiated the change?
In 2013 the sexual health and contraception services across Birmingham, UK were put out to tender by the commissioning parties Birmingham City Council and Solihull Metropolitan Borough Council. The commissioners' primary focus was to integrate the disparate services managed by different trusts and other associated providers within the region and to bring them under one contract. Another aim was for primary care to play a bigger role in providing sexual health services (SHS). There was also to be greater emphasis on safeguarding and health promotion, and for the service to deliver new ways of working by using media and technology.
How did Umbrella start?
University Hospitals Birmingham NHS Foundation Trust (UHB) developed a bid based upon the commissioners' vision and created a novel approach to how services could be delivered. UHB were successfully awarded the tender in December 2014, and merging with Solihull-based SHS, the Umbrella service was launched in August 2015. A 5-year contract was agreed, and despite a complete service redesign represented a cost saving.
What does Umbrella look like?
Based on 10 key service outcomes (Table 1) a unique partnership branded Umbrella, with UHB as the lead partner, was launched. Umbrella aspires to be the largest integrated sexual health and contraception service in the world. Umbrella aimed to turn its original service model on its head, focusing on prevention rather than treatment (Figure 1), helping to educate, empower and engage service users in order to better meet the 10 key service outcomes.
UHB already provided SHS in Birmingham and as part of the new contract took over services from other trusts as well as partnering with general practitioners (GPs), community pharmacists and a large number of third-sector organisations. This contract was to provide fully integrated sexual health and contraception services across Birmingham and Solihull.
The service follows a ‘hub and spoke’ model with the central hub in the centre of Birmingham at Whittall Street Clinic (WSC) and seven spoke clinics. The specialist service hub at WSC was expanded and offers basic and complex genitourinary medicine clinics [including syphilis and chronic sexually transmitted infection (STI) problems], basic and complex contraception and complex implant removal, psychosexual counselling, vulval dermatology and post-exposure prophylaxis after sexual exposure to HIV. Seven spoke clinics offer 6/7 days a week SHS. A specific under-25s service at the Birmingham city centre branch of Boots has been launched (following the closure of Brook in the city). In the first year Umbrella clinics have recorded approximately 100 000 attendances.
Community pharmacists have been contracted as partners to provide basic SHS (which Parsons et al.2 showed could provide a satisfactory service). There are 98 Tier 1 pharmacies providing emergency contraception and STI screening, and 13 Tier 2 pharmacies who are able to initiate the combined oral contraceptive pill, progestogen-only pill and Depo-Provera® and follow-up hepatitis B vaccinations (under clearly defined patient group directions). There is ongoing recruitment to double the number of pharmacies. Many GPs have also been contracted to expand their provision of SHS. There is an advice helpline for the partners. Both pharmacists and GPs are paid per item of service delivered.
Self-sampling kits can be ordered online by service users residing in Birmingham or Solihull and delivered or collected from any of the partners. The kits are tailored to the type of sex the service user is having and contain self-taken swabs for chlamydia, gonorrhoea and blood tests for HIV and syphilis (and hepatitis B for men who have sex with men). Test samples are then returned by the service user to Umbrella for testing with results sent back by text. The aim is to expand in as many ways as possible the number of people tested and treated for STIs.
A number of third-sector organisations have been formally subcontracted to promote signposting to Umbrella services with the goal to contact vulnerable and hard-to-reach groups such as lesbian, gay, bisexual and transgender (LGBT), drug users, black and minority ethnic community and the homeless, to name a few.
Health promotion is a fundamental part of the service, and by using the brand across the website, advertisements, social media, presence at social events (e.g. students’ Freshers' week), and via third-sector groups, healthy sexual life information can be disseminated and targeted health campaigns launched.
The Umbrella website3 provides four key functions for service users: information, ordering self-test kits, finding the nearest service, and booking appointments. It also signposts to other organisations that can help with drug and alcohol use, sexual assault and abortion services.
The combination of SHS clinics alongside pharmacy and GP partners and self-testing kits provides a significant number of access points for service users. Using the website, social media and presence at other outlets and events Umbrella has many opportunities for health promotion.
The 2016 Birmingham and Solihull Sustainability and Transformation Plan4 does not reference SHS, however Umbrella does broadly meet its aims including improved health promotion and wellbeing though information and advice, and the Community Care First strategic approach.
What challenges were there?
Those involved in the tender process found that developing a bid without prior experience involved a much greater investment of time, money and resources than expected. This affected both clinical and non-clinical staff.5
Working for a service that is put out to tender can be an anxiety-provoking time for staff. Engaging both clinicians and management during this process was important in order to facilitate and promote change in a positive way. Maintaining staff morale and reducing anxiety during the long tendering period was challenging. These challenges continued while the service was developed and implemented as staff faced uncertainty regarding their roles and location of work, as well as the potential prospect of job losses. After integration few actual job losses occurred, although a small initial turnover of staff was experienced and recruitment is ongoing.
During the integration of services a considerable amount of training had to be provided. This was provided for current UHB staff and those transferred from other trusts. A training programme was also set up for pharmacists and GPs in order to get them ready to provide their services in time for the Umbrella launch.
It was important to find suitable sites for the new service. A number of sites had to close and those services consolidated and moved to new locations, which required significant logistical planning for the transfer of facilities and of staff. This included bringing all the specialist services into one hub, and designing new clinics such as the under-25s service.
A new website for the Umbrella service had to be designed and tested, and it had to link in with self-test kit ordering and appointment booking. Umbrella also wanted to use different forms of social media for education and health promotion. It was also vital to ensure that the current IT systems provided the necessary functions to support the service as well as provide health informatics, and that they were robust enough for such a large change.
What is next for Umbrella?
Four different public awareness campaigns will be launched each year focusing on target priorities. Long-acting reversible contraception counselling by telephone has been launched. Umbrella continues to adapt following feedback submitted by service users via the website, and from staff at their forum meetings. Due to the number of services that were integrated by Umbrella there were no suitable comparable data to audit against; however, now Umbrella is a year old we have started to audit aspects of our practice and will continue to audit access to services and whether health promotions are helping us to meet service outcomes. Following the radical change to the SHS services it will be difficult to fully judge Umbrella's success in the short term; however, the public health outcomes (Table 1) will be the first important markers of its impact.
The authors wish to thank Dr Keith Radcliffe and Fiona Alexander for their input into this article.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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