Article Text

Holding up the mirror: how to use quality assurance, peer review to improve sexual health
  1. Justine Womack1,
  2. Philip Kell2,
  3. Gabriel Scally3
  1. 1Public Health England, Bristol, UK
  2. 2Rivergate, Torbay Sexual Medicine Service, South Devon Healthcare NHS Foundation Trust, Torbay Hospital, Torquay, UK
  3. 3WHO Collaborating Centre for the Built Environment, University of the West of England, Bristol, UK
  1. Correspondence to Justine Womack, Public Health Directorate, 2 Rivergate, Temple Quay, Bristol BS1 6EH, UK; Justine.Womack{at}phe.gov.uk

Abstract

The Office for Sexual Health was established in the southwest of England in January 2010 as a Department of Health pilot to bring together all elements of sexual health policy to address the fragmentation of effort created by having separate national programmes for different elements of sexual health. The Office for Sexual Health established a peer review process to quality assure the commissioning, delivery, evaluation and governance of sexual heath services across the southwest, based on a whole system, partnership approach to improvement that focused on all aspects of sexual health. This was carried out under the auspices of a sexual health services stakeholder Board, chaired by a Primary Care Trust Chief Executive, with a clear focus on providing leadership for continued improvement. The methodology involved local areas undertaking a self-assessment against national standards and providing evidence to underpin this, a review of data and a 1-day peer review visit. Each local area received feedback on the day and a follow-up report with recommendations. An evaluation of the peer review programme was carried out. The programme identified some common issues across local areas, which were addressed at an above local level by the Office for Sexual Health. Evaluation highlighted that the programme was valued by peer reviewers for sharing learning and that local areas had found the feedback constructive and helpful.

  • SEXUAL HEALTH
  • PUBLIC HEALTH
  • MANAGEMENT
  • SERVICE DELIVERY

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Why invest in peer review to quality assure sexual health services?

  • It provides a great public health opportunity to review the way organisations making up local sexual health systems work together to educate, promote health, prevent the spread of sexually transmitted infections, improve access to contraception and promote good reproductive health;

  • it promotes the use of national standards as a framework to review services against;

  • it promotes action planning and the cycle of continuous improvement;

  • it assists commissioners to get an in-depth and independent assessment of the quality of the services they are commissioning, which enriches performance data and contract review meetings;

  • it enables providers to communicate with commissioners about the potential to innovate and improve services;

  • it enables peer reviewers to learn from peers and about other models of service provision, share best practice and critically appraise their own service to inform improvements.

Public health traditions of quality assurance

There is a strong history of using quality assurance processes to improve public health systems and services. This is particularly notable in the UK screening programmes relating to both cancer and other diseases.1 ,2 Another prominent example is the British Association of Stroke Physicians/Royal College of Physicians Peer Review of Stroke Services, which was set up in 2006 to improve services for stroke patients.3 The approach has also been used widely in sexual health in England with the 2004 Medical Foundation for Aids and Sexual Health national review of genitourinary medicine services project4 and the work of the National Support Team for sexual health.5 Local government in England uses a peer review approach known as sector-led improvement.6

Experience of undertaking a quality assurance peer review programme for sexual health services in the southwest

The Office for Sexual Health was established in the southwest of England in January 2010 as a Department of Health (DH) pilot to bring together all elements of sexual health policy to address the fragmentation of effort created by having separate national programmes for different elements of sexual health.

The Office for Sexual Health established a peer review process to quality assure the commissioning, delivery, evaluation and governance of sexual heath services across the southwest, based on a whole system, partnership approach to improvement that focuses on all aspects of sexual health. This was carried out under the auspices of a sexual health services stakeholder Board, chaired by a Primary Care Trust Chief Executive, with a clear focus on providing leadership for continued improvement.

Evidence, national standards and key performance indicators

There is a strong national framework in England providing evidence of the most clinically and cost-effective interventions and standards of care. Additionally, the Public Health Outcomes Framework7 sets the national ambition for the outcomes to be achieved with indicators for monitoring progress. The following national outcome indicators relate to sexual health:

  • improving the wider determinants of health: violent crime (including sexual violence);

  • health improvement: under 18 conceptions;

  • health protection: chlamydia diagnoses (15–24 year olds) and people presenting with HIV at a late stage of infection.

The Office for Sexual Health in the southwest of England established a quarterly report to enable local commissioners and providers to review their progress against a range of indicators including sexual violence, long-acting reversible contraception prescribing rates, access to abortion, teenage conceptions, STI rates and percentage of HIV diagnoses that were late.8

The framework of evidence, national standards and key performance indicators provide the foundation for benchmarking in any quality assurance, and peer review of sexual health services (box 1).

Box 1

Guidelines and National Standards for Sexual Health*

The national framework of the most clinically and cost-effective interventions and standards of care in England includes:

▸ Service Standards for Sexual and Reproductive Healthcare (FSRH 2013)1

▸ British HIV Association Standards of Care for People Living with HIV (BHIVA 2013)2

▸ Clinical Guidance – Emergency Contraception (FSRH 2012)3

▸ UK National Guideline on Safer Sex Advice (BASHH & BHIVA 2012)4

▸ National Chlamydia Screening Programme Standards (6th Edition 2012)5

▸ BASHH: 2012 Partner Notification statement, July 20126

▸ Standards for psychological support for adults living with HIV (British Psychological Society, BHIVA & MEDFASH 2011)7

▸ UK Guideline for the use of Post-Exposure Prophylaxis for HIV following Sexual Exposure (BASHH 2011)8

▸ PH34 Increasing the uptake of HIV testing among men who have sex with men (NICE 2011)9

▸ PH33 Increasing the uptake of HIV testing among black Africans in England (NICE 2011)10

▸ Standards for the Management of Sexually Transmitted Infections (BASHH & MEDFASH 2010)11

▸ UK National Screening Committee: Infectious Diseases in Pregnancy Screening Programme—Programme Standards, Sept 201012

▸ BHIVA/CHIVA ‘Don’t forget the children’—Guidance for the HIV testing of children with HIV positive parents, July 200913

▸ UK National Guidelines for HIV Testing (BHIVA 2008)14

▸ Progress and Priorities—Working Together for High Quality Sexual Health (MEDFASH 2008)15

▸ PH3 One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups (NICE 2007)16

▸ CG30 Long-acting reversible contraception (NICE 2005)17

▸ Recommended standards for sexual health services (MEDFASH 2005)18

▸ Department of Health's You're Welcome quality criteria19

*See web appendix A for full references. NICE, National Institute for Health and Clinical Excellence.

Commissioning and contracting

In England, there are now a number of commissioning organisations responsible for different aspects of sexual health services. Local government commissions HIV prevention and sexual health promotion, open access genitourinary medicine and contraception services for all age groups, including ‘enhanced’ services from primary care. National Health Service (NHS) England commissions HIV treatment and care, health services for prisoners, sexual assault referral centres and cervical screening. Clinical Commissioning Groups led by General Practitioners commission community gynaecology, vasectomy and sterilisation and abortion services.

A national template service specification for integrated sexual health services is being developed by DH. NHS England has produced a service specification for HIV treatment and care. DH has produced a national template service specification for abortion services. Public Health England has the South West Sexual Health Task Force's Guidance on commissioning sexual health and blood borne virus services in prisons in the southwest of England.9

Running a peer review programme: the experience of the southwest of England

Peer review is undertaken for different reasons by different audiences, which can affect how quality assurance peer review is planned and delivered. Ovretveit10 has described developmental evaluation as using systematic methods and theories within an evaluation framework to support providers to improve their services and policies with the peer reviewers working in an independent role. Managerial evaluation is described as a means to monitor or improve the performance of services or policies, and check that agreed changes from earlier reviews were being implemented to ensure achievement of national standards and support improvements in outcomes.

The southwest quality assurance peer review of sexual health services combined both elements. It was conducted by the public health office based within an NHS performance management organisation South West Strategic Health Authority to ensure achievement of national standards and support improvements in outcomes. However, a peer review approach was selected in order to focus on a developmental approach, and to maximise learning across and between disciplines and geographic areas.

The boundaries of the peer review process were wide, and incorporated the whole sexual health system looking across the local authority and primary care trust commissioning environment, as well as provision of services relating to both genitourinary medicine and sexual and reproductive health elements of services.

Organisations were asked to rate themselves against a set of core standards (which brought together national clinical and quality standards of care set nationally by British Association for Sexual Health and HIV, British HIV Association, Faculty of Sexual and Reproductive Healthcare, Medical Foundation for HIV and Sexual Health and DH and National Institute for Health and Clinical Excellence (NICE)) and to submit relevant documentation to support their responses. The Office for Sexual Health collated information on demographics, needs assessment, location of services and key performance indicators. This information formed the basis of a peer review visit to each Primary Care Trust.

The purpose of each one-day visit was to use the skills and expertise of clinicians, commissioners and service providers (the peer review team) to explore specific issues in more detail, to identify priorities for improvement and to examine the progress made since previous National Support Team and Medical Foundation for AIDS reviews (box 2). It was anticipated that the peer review programme would form a 3-year rolling programme of review, but this was not realised because of the organisational changes.

Box 2

Multi-disciplinary peer review team

Each visit was undertaken by a multidisciplinary peer review team from within the southwest supplemented by staff from other parts of the country. The team had the aim of facilitating learning and the sharing of best practice and comprised:

▸ clinical lead (consultant in sexual health);

▸ peer review programme lead;

▸ public health lead and/or lead commissioner for sexual health;

▸ teenage pregnancy lead;

▸ consultant physician in genitourinary/HIV medicine;

▸ consultant in sexual and reproductive health;

▸ sexual health nurse;

▸ general practitioner with a special interest in sexual health.

Each 1 day visit followed the format outlined below:

  • an introductory briefing from the programme lead explaining the reason for the visit and its context;

  • a presentation from the organisation being visited on the subject of priorities for improvement;

  • group discussions with peers based on the issues identified from self-assessment and a visit to level 3 services;

  • the peer review team meeting to deliberate on their findings which were presented to the organisation as initial feedback;

  • a full report was provided to each local area, within 6 weeks where possible;

  • evaluation of the peer review process was undertaken, which included a questionnaire to commissioners, providers and peer reviewers.

Recommendations and reflections

There are four strands of work that are necessary after implementing a quality assurance peer review programme. These are:

  • evaluating its impact and analysing patterns of key recommendations that emerge;

  • taking action at the right scale to respond to findings;

  • reflecting on how quality assurance peer review programmes can be improved in future;

  • following-up on quality assurance, peer review to monitor progress.

An evaluation of the southwest of England quality assurance peer review of sexual health services was undertaken. Analysis of recommendations made across all 14 local areas in the southwest of England identified a number of key themes for action. The evaluation found the vast majority (85%) of the reviewers appreciated the chance to build networks with their peers and took back specific ideas to their own organisations. Many peer reviewers reported changing things in their own organisations as a result of the visits, or having been able to bring new ideas to discussions about how improvements can be made. Examples cited include:

  • the need to train and educate staff appropriately to support an integrated service;

  • learning about the process of self referral to abortion services;

  • ideas for developing service specifications around long-acting reversible contraception;

  • the importance of engaging general practitioners;

  • learning about needs assessment and data analysis.

Among those who received peer review visits, despite some criticisms of how the feedback was delivered, 82% of those who responded said that the feedback they had received at the time of the visit had been constructive and helpful to the organisations. A majority (68%) said that peer review had raised the profile of sexual health in their own organisation. Those who said that it had not done so felt that it was because sexual health already had a high profile prior to the visits.

Consideration was given to the appropriate scale of response to findings from the quality assurance, peer review programme. Each local area responded to the recommendations by drafting action plans for implementation. Action was taken by the Office for Sexual Health at a level above the local (population of 5 million), in order to support local commissioning and providing organisations to improve. This included:

  • establishing a university-integrated sexual health nursing course in the southwest of England funded through the public health nursing workforce development programme to address training provision gaps;

  • designing and implementing a project to pilot reporting very late diagnosis of HIV as serious incidents to audit factors behind very late diagnosis and inform action plans to improve access to testing.

The evaluation led to reflection on how to improve quality assurance, peer reviews of sexual health services in future. Recommendations for others undertaking quality assurance peer review of sexual health services are:

  • ensure (if possible) that staff from all units are involved as peer reviewers not just those of the enthusiasts;

  • allow enough time for the visit as the major criticism was a lack of time (1 day is probably not enough);

  • provide an advance plan to share the learning;

  • ensure the visiting team are aware of local sensitivities;

  • ensure follow-up after a period of 3 years.

Key messages

  • Quality assurance, peer review of sexual health services has the following benefits:

  • it enables clinicians and provider organisations to critically appraise services, discuss improvement and innovation and learn from other services

  • it enables public health professionals to ensure service developments meet local needs, use evidence of effectiveness and are high quality to maximise the protection and promotion of health

  • it provides commissioners with rich information about the quality of the services, and facilitates conversations about service improvement and innovation

  • National standards, key performance indicators and local intelligence on demographics and need provide the framework for benchmarking

  • There are a number of pitfalls associated with quality assurance, peer review of sexual health services including challenges with involving a range of staff (not just the enthusiasts), and being aware of local sensitivities while still providing an objective assessment

  • A timely and appropriately scaled response to the recommendations of quality assurance, peer review is required at both the local and above local levels in order to address necessary improvements

Acknowledgments

The authors would like to thank the South West NHS, local authority and third-sector organisations who participated so actively and positively in the programme. The authors would also like to thank all the clinicians, commissioners, public health and young people's specialists who contributed their expertise and time to the programme as peer reviewers. The authors would like to acknowledge the work of project manager Helen Morrison and Sexual Health Adviser Deborah Harvey in coordinating and coleading the programme.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:

Footnotes

  • Handling editor Jackie A Cassell

  • Contributors All authors have made a substantial contribution to conception and design, acquisition of data or analysis and interpretation of data; drafting the article, or revising it critically for important intellectual content; final approval of the version published. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content and to fulfil the criteria of authorship. There is no one else who fulfils the criteria of authorship and should have been included as an author.

  • Funding The South West Sexual Health Peer Review Programme was funded by the Department of Health.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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