Introduction
This section aims to consider the potential pathways for the implementation of Wrapped if it were found to be effective and cost-effective in a definitive future trial. The development of this analysis involved 11 discussions with 19 organisations and local decision-makers involved in the delivery and commissioning of web-based STI-testing services. The aim of these discussions was to explore the views of decision-makers about how Wrapped might complement existing services and their perspectives on the likely barriers and opportunities for implementation.
This chapter draws on these discussions, and analysis of a range of documentation and evidence, to consider the potential constraints and opportunities that would need to be considered as part of planning for the future potential implementation of Wrapped. We also consider how the implementation of Wrapped could support existing policy priorities and help local areas achieve their commitments and aims around improving sexual health.
Assessment of sexual health landscape
Commissioning arrangements
The commissioning and provision of sexual health services in England is complex. Commissioners with responsibility for sexual health within local authorities have responsibility for procuring services for the management of HIV and reproductive services as well as other STIs.55 Specifically, they are responsible for:
- Comprehensive sexual health services including most contraceptive services and all prescribing costs (but excluding GP provided contraception).
- STI testing and treatment, chlamydia screening and HIV testing.
- Specialist services, including young people’s sexual health, teenage pregnancy services, outreach, HIV prevention, sexual health promotion, and services in schools, colleges and pharmacies.
Other aspects of sexual health care, including but not limited to abortion services, sterilisation, cervical screening and sexual assault referral centres (SARCs), are commissioned by either NHS England or Integrated Care Systems (ICSs).55
The exact nature of service procurement for which local authorities are responsible varies considerably in different local authority regions and may be affected by historical collaborative relationships, the set-up of local NHS trusts, the type of authority in place (e.g. unitary vs. two-tier), the make-up of the geographical area, and its population and their needs. Many local authorities operate ‘block contracts’ where they procure a single provider, often an NHS trust, to deliver all the required activities and they in-turn, may sub-contract other organisations to provide the full range of services. Alternatively, the authority may operate several contracts with different providers but expect collaboration as necessary to provide effective care.
Two specific indicators for sexual health are a focus of any local authority sexual health commissioning specification. These are reductions in under 18 conceptions and chlamydia diagnoses in the 15- to 24-year-old age group.56 In order to address these outcomes, services are mandated to provide open access care to everyone within their local population, and they may also provide targeted or specialist support for at-risk subgroups to best meet local need. They must also provide free STI testing and treatment and partner notification.57 While they are not mandated to provide outreach, youth services, condom distribution, or health promotion, it is highly recommended that there is provision of this type of activity as part of a preventive approach.57 Effective prevention can help reduce the incidence of STIs and unintended pregnancy and reduce burden on and costs of services. Commissioners therefore typically include a requirement for outreach, health promotion and prevention work, including condom distribution and specialist services for young people, within their service specifications and include a requirement to report against key performance indicators (KPIs) related to these activities.
More recently, ICSs have been established in England to bring together healthcare providers and commissioners, alongside local authorities and other local partners. ICSs will plan, coordinate and commission health and care services for defined geographical areas.58 The Health and Care Bill in 2022 represented a move away from a focus on competition, with an emphasis on collaboration between commissioners, providers and other partners to meet the needs of people in the local area. It is still too early to assess what the implications of the creation of ICSs will be for the immediate challenges facing sexual and reproductive health services.59
The Faculty of Sexual and Reproductive Healthcare and the British Association for Sexual Health and HIV are the leading professional organisations dealing with all aspects of reproductive and sexual health care. Both organisations have produced relevant and informative guidance documents and standards of care related to web-based STI testing, condom distribution, outreach and health promotion. Any future implementation of Wrapped would need to work in partnership with these and other organisations to ensure alignment with guidance and standards.
Funding challenges and technological change
There have been overall reductions in funding for sexual health in recent years, with estimates suggesting that local authority spending on sexual health decreased by 14% between 2013–4 and 2017–8 (from £668 to £572 million).60 At the same time, rates of STI screening have increased.1 These decreases in funding and increasing demand have led to growing pressures on sexual and reproductive health services,61 and there is a need for local partners to work together to develop joined up, coordinated and collaborative approaches for sexual and reproductive health systems.62 This would allow a focus on achieving better outcomes, reducing inequalities, and ensuring more efficient use of resources across the sexual and reproductive health system as a whole. ICSs, with their responsibilities to plan and deliver joined up approaches to service delivery, would seem well-placed to play a role in such developments.
Alongside such funding pressures, sexual and reproductive health services have experienced rapid technological changes.63 These include the introduction of web-based STI testing and remote consultations. Digital sexual health interventions have also been implemented for a range of other purposes including partner notification and care pathways.64 In addition, there has been expanded provision of sexual and reproductive health services in a greater range of settings such as pharmacies and community settings.62 There are calls for a greater focus on how services can be provided in ways that are more sustainable and equitable, embracing the potential of digital health to improve and increase access to screening, testing and care.
Assessment of health systems into which Wrapped could be implemented
As sexual and reproductive health systems vary considerably in England, there are a range of possible options for how Wrapped could be implemented in the future, if a definitive trial demonstrated effectiveness and cost-effectiveness. As part of this feasibility study, it was therefore important to assess and evaluate different strategies and opportunities for embedding the Wrapped intervention within these systems.
The provision of web-based STI testing is recommended within English national commissioning guidance.65 A range of models are currently established, with a rapid expansion in web-based STI testing particularly evident since the COVID-19 pandemic.66 The involvement of commercial partners in web-based STI-testing delivery is varied. In some areas, commercial partners are contracted to provide all aspects of these services and follow-up, whereas in others they provide only certain aspects of delivery. For example, commercial partners may provide the website, ordering and distribution of STI self-sampling kits, laboratory services and triage, while local sexual health clinics provide clinical care and follow-up.67 Such services may be commissioned by an individual local authority, or by a group of local authorities who form a consortium (e.g. London’s SHL service).68 In contrast, in some areas a local NHS Trust may provide all aspects of web-based STI testing and follow-up ‘in-house’.69 There are also a number of other approaches, determined by local population needs, historical patterns of provision and contracting arrangements.
Condom distribution schemes are also varied, with some schemes delivered directly by local authorities, and some commissioned out to sexual and reproductive health service providers, who may themselves partner with other organisations.70 All of the local commissioners we spoke to had a ‘C-card’ scheme in place whereby young people could register for free condoms and lube which could be collected from range of in-person services such as pharmacies and youth centres. We are however aware of some existing and planned services offering condoms and lube through online registration/ordering and postal delivery. These include for example established schemes operated by Solent NHS trust and the Royal Borough of Greenwich, and a scheme currently undergoing tender which was jointly put forward by Devon county council and Torbay council. Planning for the future implementation of Wrapped would need to consider alignment with different models of web-based STI-testing provision and existing online and walk-in condom distribution schemes.
There are two main routes for the future implementation of Wrapped. Firstly, the service could be hosted and delivered by one or more of the commercial web-based STI-testing providers operating across England. Secondly, for local authority areas managing their own STI self-sampling services ‘in-house’, the intervention could additionally be devolved to the provider in that local area. It is anticipated that both sets of providers would have responsibility for website maintenance, resolving technical issues, and fulfilling orders, and would need to have the expertise/resources available to manage and maintain the intervention. It would be recommended that the academic team be retained (via sub-contract) to review and update the content on a regular basis. There could be scope for local variation and branding to match other services in the local area via either route (commercial providers are able to tailor the services they offer according to commissioner requirements). Each route has its own strengths and limitations. The first approach would allow dedicated technical expertise and development, and efficiencies associated with purchasing supplies at greater scale. In contrast, a devolved approach might allow greater flexibility and tailoring to needs and preferences of local areas. Partnering with one of the main commercial web-based STI-testing providers would allow Wrapped to be implemented in many areas simultaneously, as part of existing commissioned services. However, this would need to be balanced around commercial interests and considerations which might prevent the intervention being available in areas where web-based STI-testing services are maintained ‘in-house’ within the NHS.
Our conversations with the two largest providers of web-based STI self-sampling have demonstrated that there is interest in delivering greater support to users around condom use and recognition that what is currently offered could be improved. Both have begun providing condom distribution (online order and postal delivery), bundled up with the ordering of self-sampling kits, to users in a small number of areas (two and one local authority areas respectively for each provider). Both noted that while demand for this service was high among young people, commissioners despite recognising its value and benefits, often reported being unable to procure this within their current funding envelopes. There was a strong sense from one of the providers however that this picture was changing as local areas continually strived to achieve cost efficiencies (see Assessment of sexual health landscape). This could include for example, local areas looking to move all or some of their existing in-person condom distribution services online.
One of the two providers we spoke to felt that Wrapped was inconsistent with the ‘tone of voice’ conveyed through their own service and would want to see some changes made prior to any future implementation. This underlines the importance of ongoing stakeholder involvement as interventions move to implementation, and the routes to market and thereby key influencers, become more defined. Prior to any future trial, further stakeholder engagement would therefore be required to create a version of Wrapped which balances the needs and wishes of end users and potential commissioners, without compromising its theoretical basis.
We conducted a range of discussions with commissioners and providers in local areas. All those consulted felt that there should be some flexibility in the overall approach to implementation, as the commissioning landscape has evolved and is likely to undergo further change. For those who provided web-based STI-testing services ‘in-house’ in the local NHS, there was a suggestion that services would need be tailored for the local context and aligned to existing services. For those who partnered with commercial organisations, there was a perception that an enhanced offering to include sexual health promotion and outreach alongside condom distribution would be of interest, however, pressures on budgets would need to be borne in mind (see below), and there would need to be clarity about the added benefit of the enhanced offering compared to standard web-based STI-testing services.
Barriers and facilitators of scale-up
Discussions with providers and commissioners revealed that there are a range of barriers and facilitators to be considered for future implementation of Wrapped. A key factor was funding pressures and the reductions in spending on sexual health in recent years. There was a general perception that the costs and benefits of Wrapped would need to be carefully analysed and articulated, given the challenges associated with finding or reallocating resources for new services and interventions, and the intense pressures on local sexual and reproductive health budgets. There were also perceived challenges associated with the complexity of local commissioning arrangements, which would require a range of partners to be involved in any decision-making, and varied priorities would need to be considered and addressed.
There were some facilitators that were evident in these discussions. In particular, since the COVID-19 pandemic, there was an increasing recognition of the need and potential offered by digital services. In addition, there was an appreciation that STI rates were continuing to increase in many areas, and hence new approaches to information provision and sexual health promotion were needed. There was also a recognition that since the pandemic the importance of tackling health inequalities had been highlighted, and this was seen as important as STIs disproportionately affect marginalised groups. Hence, in terms of a future trial, commissioners and providers not only wanted outcome data concerning the effectiveness of Wrapped in reducing STI rates overall, but also clear data about its effects on underserved groups, and those who experienced reinfection.
Summary
Funding pressures on sexual health budgets mean that commissioners are increasingly looking to ways to reduce their costs while still meeting service requirements. These requirements include STI testing and treatment, and many areas are now commissioning third parties to provide web-based STI testing. Other areas have their own ‘in-house’ operations. While local authorities are not mandated to have STI prevention programmes in place (e.g. health promotion, condom distribution), this is recommended and there is recognition from commissioners that this could help to reduce burden on and costs of services. Many areas have in-person C-card schemes in place for condom distribution and there are a small number of areas that supplement this with online condom ordering and postal delivery. Web-based STI-testing providers are also beginning to offer this to commissioners as an add-on service, allowing service users to request a bundle of condoms at the same time as ordering a STI self-sampling kit.
Wrapped could be implemented as an add-on module offered by one or both of the two major web-based STI-testing providers. This could be offered in addition to their current condom distribution module or alongside it. As condom distribution is new for both organisations, the service is not yet established and there is scope and flexibility to adapt. Both organisations have shown an interest in Wrapped, albeit for one of these, some changes to the intervention would be required before they would consider offering it as an add-on service. For local authorities who have commissioned their own ‘in-house’ provision of STI web-based testing, Wrapped could be implemented directly within their existing web-based service. Commissioners (of third-party providers and those with in-house operations) have shown interest in Wrapped and have provided us with valuable information about what data they would need from a future trial to help them decide whether Wrapped is effective (including for underserved groups) and should be made available for users in their local area. The major barrier to implementation of Wrapped for all commissioners is cost. However, the increasing movement towards digitisation of services to help reduce costs, which could include moving condom distribution online, may free up some budgets to support the implementation of Wrapped. We would argue that while improving access to condoms through online distribution is important, the effective targeting of other determinants of condom use (such as increasing behavioural capability and self-efficacy for putting on condoms correctly) is necessary for behaviour change.