Sex clinics show how competition can improve England’s NHS

FOR THE easily embarrassed, getting tested for a sexually transmitted infection (STI) is a less excruciating process than it used to be. A kit is delivered to the patient’s home in plain packaging, no more than 48 hours after it is ordered, typically including a container for a urine sample, a swab or the tools for a blood test. The test is done at home and, once returned, results are delivered by text, within four days. Nervous types who want to avoid a trip to their local clinic will be glad that this free service is now available in areas including Birmingham, Essex, Norfolk and much of London.

A decade ago sexual-health clinics tended to be conservative facilities, hidden away in quiet corners of hospitals. Since then there has been something of a consumer revolution. Clinics have become more open, tech-savvy and attentive to their users, who are growing in number. Despite cuts of 14% to local-authority funding of such services between 2013 and 2017, the number of visits to sex clinics rose by 13%, to 3.3m a year. At a time when the health service is rethinking how it operates, the burst of innovation in sex clinics holds lessons for other parts of the NHS.

Sexual-health services have been given a boost by improvements in HIV care. Finding people who have the disease is a priority in public health, because with treatment they will no longer pass on the infection and can now lead long, healthy lives. But there are also organisational reasons for the innovation. In most of the NHS, patients are sent to specialist services by GPs, or family doctors, who act as gatekeepers. By contrast, anyone can walk into a sex clinic without a referral. As a result there is a strong incentive for clinics to attract patients, who bring funding and help doctors with research, says Axel Heitmueller of Imperial College Health Partners, a network of health-innovation experts.

In parts of the country with multiple specialist providers, there is also competition between clinics. As one clinician in London puts it, “There is a sense of keeping up with the Joneses.” 56 Dean Street, which opened in 2009 in Soho, London’s gay village, was a pioneer. On a Friday lunchtime it does a brisk trade as a diverse crowd pops in to use its services. Two members of staff were given freedom by the local NHS trust to come up with a new approach, tailored to the needs of patients. The result mixes sharp design, a central location and convenient services. Next came Dean Street Express, an automated facility which gives users quick results.

Since then other trusts have opened more convenient clinics, including one under the arches by Waterloo station to target commuters. The focus on the lifestyle of users is apparent in other parts of the country, too. In Leicester a clinic will soon open in a shopping centre, replacing an old branch of TK Maxx, a discount fashion chain. Mobile clinics visit underserved districts or vulnerable groups. In rural areas, this means dropping by market towns. In urban ones it can mean hosting clinics in gay saunas. (There is “no obligation to use the sauna facilities”, the website assures.)

Happy clappy

Trusts have been quick to copy good ideas, often from women’s or LGBT groups, who can offer insights into affected communities. Since 2003 free chlamydia self-testing kits have been offered to under-25s. Every year Public Health England, a government agency, funds pilot schemes (including one to spread HIV knowledge on prison radio and another to offer testing kits in vending machines).

Innovation has helped to maintain standards at a time of tight budgets. Guy’s and St Thomas’ Trust in London has cut its number of sexual-health clinics from six to three, but helps more people than before, partly thanks to better use of technology to do things like manage queues and target high-risk patients. In some regions follow-ups for people being given the all-clear are now done by phone, rather than in person. The use of technology can lead to cock-ups: in 2016 the trust that runs 56 Dean Street was fined £180,000 ($236,000) after the clinic mistakenly copied 781 people into an email, revealing the identities of HIV patients. But on the whole it has made services more convenient, while driving down costs. STI self-testing costs the state around £25 a pop, a sixth of the cost of an initial visit to a clinic.

Nevertheless, there are signs that the cuts may be harming accessibility. A mystery-shopping exercise published in 2017 found a fall in the proportion of people with STI symptoms who were able to get an appointment in 48 hours—a worrying finding at a time when rates of syphilis and gonorrhoea are rising. A big organisational shake-up has also caused disruption. In 2012-13 responsibility for commissioning sexual-health services (except HIV) moved from the NHS to local authorities. A survey by Public Health England found it hampered “seamless care”. It has also delayed the roll-out of pre-exposure prophylaxis (PrEP), a drug that protects against HIV.

Current NHS plans seek to overcome fragmentation (both in sexual-health services and elsewhere) by bringing providers and commissioners together, in the hope that they can work out how to raise standards. The example of sex clinics suggests it is worth thinking more about the incentives they have to innovate, whether coming from patient choice or elsewhere, says Mr Heitmueller. Changing behaviour is hard in any big organisation. Sexual selection offers one model for how it can be brought about.