Women's Health Hubs: a rapid mixed methods evaluation

Conceptualisations of women’s health

Women’s health has historically been confined to a focus on sexual and reproductive health, including childbearing and menstruation. However, there has been a call for broader conceptualisations:1,2

Women’s health involves women’s emotional, social, cultural, spiritual and physical wellbeing and is determined by the social, political and economic context of women’s lives as well as by biology. 2 (p. 118)

The focus on sexual and reproductive health may be linked to the role that contraception and abortion access has played in transforming women’s autonomy, to make choices about having a family. 3 Organisations such as the Faculty of Sexual and Reproductive Healthcare conceptualise women’s health as existing on a continuum, with experiences and needs throughout the life course. 2–4 This acknowledges that needs change alongside life events and with age and draws attention to both stages and points of transition (e.g. the start of menstruation through to menopause). 3,4 This enables a preventive, rather than just reactive, approach to women’s health and extends beyond a medical model to improve health and well-being across generations. 4

Service provision

Women’s health needs can be understood and grouped in a number of ways and include pregnancy-related (e.g. pregnancy planning, fertility), sexual health-related (e.g. sexual pleasure) and non-pregnancy-related (e.g. incontinence). 5,109 These are met by a range of providers, professionals and venues, which also varies locally, as described in Box 2.

In England, these services are provided in a range of primary and secondary care settings, with a variety of funding and commissioning arrangements. The complexity of the landscape often means that provision is not well integrated, and artificial divisions between contraception and reproductive health have led to challenges in access to contraception in England. 6 Following the 2012 Health and Social Care Act, responsibility for the provision of contraception, sexual and reproductive health provision was split between different commissioning bodies, for example local authorities, NHS England, and Clinical Commissioning Groups (CCGs), which have now been replaced by Integrated Care Systems (ICSs). 6,7 Services have been described as ’shaped by the source, availability and amount of funding available, rather than by women’s needs’ (p. 12). 6 Local authorities have largely had responsibility for preventive and public health services, including sexual health and contraception services, whereas the NHS has responsibility for the assessment and treatment of disease in primary care (including prescribing) or via referral for specialist health services. This fragmented model of commissioning can result in services that are disjointed, which may not reflect local population needs, and may lead to unwarranted variation in spending by local organisations, and difficulties in comparing investment between localities. 7 A particular consideration is that long-acting reversible contraception (LARCs), specifically intrauterine devices/systems (coils), may be required for either contraceptive purposes or gynaecological reasons. Separate sexual health and gynaecology commissioning arrangements mean that services are often not funded to provide coils for both reasons in one setting. A case has been made for collaborative commissioning, with a clear mandate and resources, supported by strong public health leadership. 8

Several factors seem to be interacting to increase perceived pressure on women’s health services: NHS budgets are under pressure, and local government has experienced cuts to funding; there are workforce and training gaps, for example insufficient staff with the right skills and experience. The COVID-19 pandemic and waiting-list backlogs have impacted on access. 4,6,9 Suggested improvements have included more strategic leadership accountability, models of care that incorporate sexual and reproductive health needs, sustainable workforce models that provide care for those with complex needs and provision for all. 4

Women’s experiences

The challenges described above can result in negative experiences for women seeking care. Women may be moved between services due to gaps in care pathways, have difficulty accessing appointments (including long waiting), experience variation in interest and expertise at the first point of contact, and may be required to attend multiple appointments with different providers, wasting time and resources. 6 Women are ‘being left without clear direction of where to access the support and services they need’,10,11 as care is not structured around their needs. 10,11

The Better for Women report by the Royal College of Obstetricians and Gynaecologists emphasised the need to focus on and adopt a life-course approach to women’s health. 9 As part of the report, a UK-wide survey of women was commissioned, which highlighted poor access to basic women’s health services, barriers to care and a need for improvements to services. 9 To inform the first Women’s Health Strategy for England,12 the government collected evidence from women. Five topics were identified for prioritisation: gynaecological conditions; fertility, pregnancy loss and postnatal support; the menopause; menstrual health and mental health. 13

Areas in need of improvement included women not feeling heard and difficulties with service access. 14 Women reported that their symptoms were often dismissed and that obtaining a diagnosis was challenging. Most respondents relied on family or friends for information and identified a particular lack of information on menstrual well-being, menopause and gynaecological conditions. Being taken seriously and offered appropriate treatments for menopause were further areas where shortcomings were reported. The majority of women suggested that service access was not convenient regarding location or time. 14 Women suggested changes at system level, including hubs and drop-in centres, as well as greater diversity in provision. 14 The evidence collected supported the need for a more joined-up approach to women’s health care and the implementation of WHHs, including one-stop shops (discussed further later).

Geographical variation and inequalities

Across the country, there is also variation in the quality and availability of sexual and reproductive health services, with a lack of ownership and accountability in the system for women’s healthcare needs. 4,9,15–17 This has been shown to particularly affect women seeking support for fertility treatment and menopause4 and cervical screening. 18 It has been suggested that political prioritisation of women’s health services is required to drive improvements, particularly for women from disadvantaged backgrounds, who experience the worst outcomes. 18 There are significant inequalities in sexual and reproductive health, with young people and ethnic minority groups among those disproportionately impacted. 15,19 For example, unmet need in contraception access is suggested by higher abortion rates among people from socially disadvantaged and/or ethnic minority backgrounds, and under 25s. 4 Additionally, women with disabilities can face barriers in accessing cervical screening or contraception. 4 It is also important to consider lesbian, gay, bisexual, transgender, queer, questioning and other sexual and gender identities (LGBTQ + ) service users. There is a paucity of high-quality research in this area, and routine data are not often collected in a way that enables appropriate examination of health inequalities. 20 Long-standing inequalities in service access and provision for women from disadvantaged and minority groups have likely widened because of COVID-19. 18

Development of Women’s Health Hubs

In recognition of these issues, there have been increasing calls for a more collaborative, holistic and integrated approach to delivering women’s health care, designed around women’s needs. 6,9,15 Local teams across the UK responded to the challenges in delivering services by establishing WHHs to improve access, experience and outcomes for their population, to address inequalities, and reduce costs. Some known models were already well established, while others were set up and/or starting to function around the time of the COVID-19 pandemic. Hubs function to meet the integrated needs of women’s reproductive health care by providing access to a practitioner with appropriate skills, in a community setting (usually primary care, although not necessarily at their own practice or provided by their own practice team). Although still emerging, these early models were highlighted as best practice,11,21 with wider roll-out recommended. 9 There appeared to be an increasing expectation among women in the population that healthcare provision needed to change. For example, in the UK-wide Royal College of Obstetrics and Gynaecology women’s survey, almost half of participants supported the idea that one-stop women’s health clinics and/or drop-in facilities would improve access. 9

The Primary Care Women’s Health Forum has actively promoted and supported the development of new ‘hub’ models. It has drawn together the expertise of hub leaders across England, and launched a WHH toolkit, to support others to implement these models. 11,93 Their work is evidence of the significant learning available within the professional community from the early experience of hub development, but it also illustrates the ongoing diversity of models and local variation in provision.

Evaluation aim

The overall aim of the evaluation was to explore the ‘current state of the art’, mapping the landscape, studying experiences of delivering and using hub services and defining key features and early markers of success to inform policy and practice. Specifically, the study evaluated why, where and how hubs have been implemented; why different approaches have been taken; how inequalities have been considered and experiences of implementation, delivery and receiving services. The evaluation explored the successes and challenges of hubs and potential improvements, including different stakeholder group perspectives of what hubs are intended to achieve, and whether hubs were making progress towards this. It also explored what is known about performance, outcomes and costs and how they are measured.

Evaluation questions

The study sought to answer the following evaluation questions:

1. What are WHHs, and is there variation in how stakeholders name and define them?

2. How many WHHs have been established or are in development across the UK, where are they, and what are their characteristics, including models of structure, commissioning and delivery?

3. Why have WHHs been implemented, and how are they intended to address health inequalities?

4. What have WHHs achieved to date? How do WHHs achieve this?

5. What are the experiences and perspectives of staff regarding WHH set-up, commissioning, funding, implementation and delivery?

6. What are the experiences and perspectives of women who have used hub services?

7. How are WHHs’ performance, outcomes and costs measured, and how might they be measured in future?

Development of the evaluation design

The protocol was developed after a detailed scoping phase in early 2022 which included:

• Interviews with 10 key stakeholders to gather insights and experiences of WHHs and to define the evaluation scope (this included WHH leaders, national policy and practice leaders and representatives of key organisations including the Primary Care Women’s Health Forum, Faculty of Sexual and Reproductive Healthcare and Royal College of Obstetricians and Gynaecologists).

• Identification and review of relevant published and grey literature to locate existing WHHs to understand the context and inform evaluation design and questions.

• Establishment of a Stakeholder Advisory Group to support the evaluation.

• A stakeholder workshop to refine the evaluation focus and questions.

• A meeting with three women with lived experience of NHS women’s health services to discuss their views about what the evaluation should explore.

Stakeholder Advisory Group

A multidisciplinary Stakeholder Advisory Group provided expertise and advice to support the study, meeting three times. The group discussed a range of topics related to women’s health, the Strategy and the evaluation. We also sought advice and guidance from the group on an ad hoc basis throughout. Details on the group’s specific input can be found in Chapter 3.

Women’s Advisory Group

The evaluation involved women with lived experience of NHS care for women’s health issues from the outset. Three women took part in the scoping work, and subsequently joined our Women’s Advisory Group. The Women’s Advisory Group provided input throughout the evaluation and used lived experiences to shape the project. This comprised a diverse group of seven women with varying experiences of NHS care for women’s health issues, including smear tests, endometriosis and menopause. The Group was chaired by a woman with experience of public involvement in research and evaluation. The team also met separately with an eighth member who was unable to join the main group meetings, who provided additional input including on terminology, the hub concept and delivery and inequalities. Our public contributors were drawn from across England and included different demographic backgrounds including age, ethnicity and sexual orientation.

Four virtual meetings were held with the group at key points in the evaluation. Meeting dates were agreed with the Group in advance, and any relevant documentation, for example topic guides, was shared before each meeting, along with meeting slides and an agenda. Where members were unable to attend, they could meet researchers separately later, or provide feedback via e-mail.

The Group helped to shape the study, provided advice and feedback, and contributed to framing and prioritisation of findings. Their input included:

1. Highlighting the need to include a more diverse group of women who may not access WHHs. As a result, we changed the methods to include focus groups with women in communities to hear about awareness and understanding of hubs, and any potential barriers to access.

2. Advising on appropriate ways to recruit women to participate, suggesting routes for data collection with patients using hub services and stressing the importance of flexibility and appropriateness, being mindful of women’s differing needs and preferences.

3. Providing guidance and perspectives regarding important criteria for selecting the hubs to be involved in in-depth evaluation.

4. Suggesting that we explore patient pathways in/out and back into WHHs, and how this is understood by and communicated to women.

5. Providing input into the design of evaluation tools, reviewing tools and providing feedback.

6. Reviewing the plain language summary for the protocol and report.

7. Reflecting and commenting on emerging findings and their relevance to women.

8. Providing advice about framing and disseminating the findings, particularly for the public.

9. Reflecting on the concept of WHHs as emerging models of care.

What do we know about Women’s Health Hubs?

Although WHHs are a relatively new concept and we did not identify any published academic literature describing or evaluating their effectiveness, the grey literature offers important insights into these models and how they are intended to improve health services for women. The Primary Care Women’s Health Forum WHH webpages describe what a WHH is at a high level,11 and share early learning through case studies34 and a toolkit to support services with planning and implementation. 35–37 Key messages from the Primary Care Women’s Health Forum case studies are summarised in Table 2.

A number of models and ways of organising and providing women’s health services are described in the Primary Care Women’s Health Forum case studies and wider literature on WHHs. These include hub-and-spoke models,34 one-stop-shop models,39,43 PCN-based models,34 inter-practice referral models44 and community gynaecology models. 34 However, definitions of these terms are unclear. In our findings, we explore and, where possible, define models.

The case studies and resources provide valuable evidence to support hub implementation. Case studies were developed collaboratively with leaders and early implementers in WHHs. However, there has not been any comprehensive mapping of WHHs to date, and descriptions of models in the grey literature vary in detail and focus, with no in-depth exploration of the experiences of WHH staff and women using services. Our evaluation builds on and addresses the gaps in current evidence.

What is known about ‘hub’ models in health care?

Hub models are increasingly mentioned in NHS policy across a variety of contexts and are being implemented for different purposes across England. For example, NHS England recently set out plans to create health and well-being hubs, known as ‘Cavell Centres’, aiming to bring health and social care services together in one building. 45 Hub models in the literature focus on a number of different health conditions and services, such as child and family hubs, which include voluntary and community organisations pooling resources. 46 However, the evidence for hub models has not been synthesised, and there is no agreed definition of a hub, and terms are used inconsistently in policy and academic literature. Hubs and similar models can be adapted to a range of contexts, and a key message from the evidence is that one size does not fit all. 47–50

Hub-and-spoke models are described as providing complex services in a central ‘hub’ (typically a hospital), linked to a network of more local ’spokes’ (less specialised hospitals/community venues). 51 A model may have a single hub or multiple hubs; similarly, any number of spokes may feature in a hub model. 52 The activities within hubs and spokes may vary, along with the way they are managed. For example, different spokes may provide different services and there may be variation in the way women access them. 52 In hub-and-spoke models of maternity services, a hub may be a consultant-led ward in a hospital, surrounded by midwifery-led units. 53

Hub models can provide care as a one-stop shop, meaning a broad number of services are available under one roof,54 ideally in a single visit, reducing the need for numerous appointments. 55 There are a range of examples of one-stop shops, bringing together professionals and service providers to improve and integrate care. 56–58 These models have been described as user-focused, providing opportunities for staff development, and were recommended by the Royal College of Gynaecologists and Obstetricians during COVID-19 to reduce risk of exposure for staff and women. 59 One-stop-shop models in primary care have been associated with improved patient satisfaction, particularly with continuity of care and accessibility. 54 In an evaluation of a GP hub-and-spoke model of sexual and reproductive health services, a sexual health centre acted as a hub, with GP practices as spokes. The model was led by nurses, and hub staff provided training and education to upskill nurses in sexual and reproductive health care, so that the GPs and nurses could provide human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing and treatment, with more complex cases referred to the hub. 60 The model was found to be acceptable and feasible by women and by clinicians, integrating with usual practice well. 60 However, there are concerns that providing all services under one roof may have a negative impact on the sustainability of standalone services, and data on the cost-effectiveness of these models are inconclusive. 61

Bostock and colleagues describe a number of limitations in evaluations of hub-and-spoke models in health care, including a lack of clarity in the definition, the absence of service user voice in evaluations, and limited evaluation of the role of context. 52 Predictors of a ’successful spoke’ are also uncertain, specifically in the context of SRH services. 60 This evaluation adds to a limited body of literature on hub models in women’s health care.

Definitions

There is no widely accepted definition of integrated care, which has been described in the literature as ‘diverse’, ’synergistic’, ‘ambiguous’ and ‘dynamic’, evolving to meet the changing needs of a population. 65–67 Integrated care can be:

… best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes … [it] is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. 67 (p. 446)

Integrated care is generally understood to be co-ordinated, be that through combining physical resources (e.g. rooms and buildings), by workforce, through bringing together professionals from different services, and by systems, for instance integrating patient record systems across sectors of care. 65 Integrated care involves the removal of boundaries within the health sector (such as those between primary and secondary care), between health and associated services (e.g. health and social care) or both (e.g. in bringing specialised teams together to address both mental and physical health aspects of a condition). 25 Integration can be vertical, with integration between organisations involved at different stages of the patient pathway (e.g. hospitals running GP practices) or horizontal, between organisations at similar stages of a patient pathway, such as GPs working within PCNs. 68

Aims of integrated care

Integrated care intends to achieve the NHS quadruple aim of improving patient experience, population health, the efficiency of healthcare systems (i.e. value for money) and workforce well-being. 69 Integrated care initiatives also often aim to address health inequalities,70 and evidence suggests that benefits of integration may be greater in deprived areas, by improving access to care for underserved populations. 70

Models often tend to be implemented by high-performing early adopters. 70 They are often run by passionate volunteers, by organisations with a strong history of integrated working, and where funding and guidance are provided from national bodies. 71,72

Aims of integrated care vary by stakeholder groups and are often contradictory, meaning positive outcomes for one stakeholder group may lead to negative outcomes for others. 73 Integrated care can require investments in space, specialist resources and staff, and time for patients to be heard, and this does not always align with organisational objectives to reduce costs. 67 A common feature of integrated care is patient-centredness,65,71,73–75 designing services around the needs, preferences and values of patients and families and the type of care they feel is required. 65,71 Our evaluation explores a range of stakeholder perspectives, including those of women using WHHs and others in the community who may find it more difficult to access services. A summary of aims of integrated care can be found in Box 3.

Benefits of integrated care

Stated advantages and outcomes of models of integrated care are numerous and relate to healthcare resources and health system function (e.g. efficiencies in the workforce), improved quality of patient care (e.g. improvements in mortality and morbidity, a reduction in unnecessary harm) and outcomes for staff (e.g. staff work satisfaction). 47,65,73,76–79 For example, the NHS has advocated models of care which bring ‘care closer to home’ for many years. 47,76,77,80,81 Outcomes for integrated care models are often context-specific, meaning they may be unique to the demographics and needs of a local population and geography (e.g. due to variations in transport and proximity to a patient’s home of services). 66,71,72

The advantages of integrated care models may vary according to clinical severity and complexity. It has been suggested that integrated care has the potential to improve outcomes among patients with the most complex needs, particularly given the risk of increased costs of care in these groups. 73

Evidence

The relationship between greater care integration and outcomes is complex, and evidence of effectiveness of integrated care is mixed. 65,73 This is, in part, due to the methodological difficulty of evaluating integrated care initiatives. Programmes are heterogeneous in terms of interventions and outcomes,70 and existing evidence has been reported to be of variable quality and reliability, largely observational and small scale. 67,70 Nevertheless, there is evidence in the literature of improvements in patient experience, health outcomes, staff experience and cost savings following the implementation of integrated care models. 70–72 For example, stakeholders involved in an early evaluation of vertical integration describe the overall impact on health system costs as beneficial, with improvements in managing patient demand. 82 In children and young people’s services, a range of benefits have been described. These include better communication between clinicians and patients, care received closer to home and improvements to quality of life, staff experience and a reduction in unnecessary tests. 70

The evidence of cost-effectiveness of integrated care remains limited and mixed, with some studies identifying potential savings, but others reporting increases in costs. 67,70,71,73,84–87 This is somewhat paradoxical, in light of consistent strong support for integrated care among decision-makers. 67,73 Conclusions from evaluations and reviews of the evidence show a need for better understanding of which integration approaches work best, in which contexts, and what influences success. 71 Concerns have also been expressed about safety, affordability, balancing efficiency with choice, expectations about impact not being met and failure to integrate rather than simply co-locate services. 47,81,88

Integrated care theory

A variety of frameworks is available to describe and explore integrated care, and they can be used to inform evaluations of these models. 89,90 In this evaluation, we drew on integrated care frameworks to explore the different dimensions of integration in WHHs. 90

Available frameworks have been developed using systematic literature reviews and stakeholder and expert consultations. They explore how care is integrated (i.e. the specific integration activity or intervention implemented), and the level at which the integration takes place (e.g. meso/mico/macro levels). 65,91 There was no single framework of integrated care that was best suited for this evaluation. However, Table 3 summarises five key dimensions of integration we explored, underpinned by a framework from van der Klauw. 92 This was selected due to its comprehensiveness, clear presentation of integrated care and utility for the evaluation. This was supported by theory from two other frameworks: Singer et al. 65 and Hughes et al. 67

We used this table to assist in the exploration of forms of integration in the hub models in our evaluation, which is described in the relevant sections of the results and discussion. There is a need for further empirical research to assess the validity of integrated care frameworks.

Work package 1 participants, sampling and data collection: mapping the current landscape and context

Work package 2 participants, sampling and data (exemplar hub evaluation)

Staff interviews

In each site, researchers interviewed staff involved in the hub, and staff in the wider health system, based on their roles in relation to WHHs. Individuals were identified through discussions with the local hub leads to identify key roles, and by snowballing via other interview participants. Between September 2022 and January 2023, 40 staff were interviewed (Table 7). Lead hub stakeholders facilitated contact. Sampling focused on identifying a range of key informants in different roles and contexts. Participants included GPs, nurses, sexual and reproductive health consultants, commissioners, administrators and referring GPs. Potential interviewees were approached by e-mail, which included a consent form and information sheet. Interviews were conducted face to face, online or by telephone, with most conducted online. In two sites, researchers interviewed staff at the hub site. Written or verbal consent was obtained from all participants. Participants either returned a signed consent form (hard copy or electronically by e-mail), or, in instances where verbal consent was provided, interviewers read out consent statements at the beginning of interviews and asked participants to confirm their consent. This process was audio-recorded. Semistructured interviews followed two separate topic guides, developed by the study team and informed by the evaluation questions and emerging findings from other WPs. Topic guides were tailored for (1) WHH staff and (2) staff in the wider health system. Topics included hub aims, experiences of implementing a hub and delivering services, what worked well and less well, early impacts and links with local systems. The majority of interviews were 45 minutes to 1 hour in duration.

Interviews with service users

Interviews were conducted with 32 women who had used their local WHH in each of the 4 sites to explore their experiences (Table 7). The Women’s Advisory Group recommended a flexible approach to recruiting service users to participate, tailored to consider the context in each site. A convenience sampling approach working through clinical gatekeepers was taken, with two different approaches adopted in different sites, described below:

• In three sites, hub professionals shared information about the evaluation with women during appointments. A ‘consent to contact’ approach was adopted, whereby those interested were asked to consent for their details to be shared with researchers who would contact them to arrange an interview. Interviews were undertaken either by telephone or by videoconferencing [Zoom (Zoom Video Communications, San Jose, CA, USA) or MS Teams], depending on interviewee’s preference.

• In one site, six of the seven women who took part were interviewed face to face, by a researcher visiting two different hub clinic locations on that day in order to recruit women from different geographical areas and hub settings (a seventh woman also took part online). The health professional running the clinic shared information about the evaluation with all women attending the clinic, and those who were willing to be interviewed met with the researcher in a separate area following their appointment.

Information about the study, including background details and study purpose, was provided to participants via information sheets and verbally, with participants able to speak with researchers should they have had any questions. Verbal or written consent was obtained as described earlier. Women interviewed face to face provided written consent in person. Interviewees received a £10 shopping voucher as compensation for their time. The topic guide was informed by the evaluation questions, emerging findings from other evaluation work, and insights from the Women’s Advisory Group. It was also reviewed and refined by the study Women’s Group. It included questions exploring awareness of women’s health services, experiences of services including accessibility and satisfaction, and what could be improved. Women were also asked to complete a demographics form, though it was not possible to collect this from all participants (Table 8). Of those for whom it was possible to collect this information, most of the sample were White British, all described their sex as female and over two-thirds left education at or before 18.

Focus groups with women in local communities

Following input from the Women’s Advisory Group (see Chapter 5), the evaluation plan was extended, to add focus groups with women in communities perceived by hub leaders/stakeholders to be less likely to access a hub. The aim was to capture the experiences of women who may find it harder to access WHH services.

One focus group was undertaken in each site (Table 9), two were face to face in local community venues and two were online (to suit availability and preferences of the women taking part). Demographic information is presented in Table 10. A purposive sampling approach was used to identify community groups to host focus groups, in populations where WHH site leads/stakeholders reported barriers to access to women’s health services or those who were less likely to engage with services. In three sites, a community group was identified to host a focus group via the lead hub stakeholder, who helped the team broker access and facilitated recruitment. In the fourth site, where the hub lead did not have an existing link, the team identified and contacted a suitable community group through one of the other interview participants. Overall, a convenience sampling approach was taken for participants, where a researcher attended existing group events, and group members were invited to join a group discussion during/after their usual session. However, for one of the virtual focus groups, a separate meeting was arranged at the request of the participants.

Materials were provided to the group by the group’s leader in advance, to ensure members were aware that a researcher would be attending and understand what may be involved, including that participation was voluntary. The Women’s Advisory Group advised on content and members reviewed drafts of topic guides and information sheets for women service users and focus groups. The group discussion guide included questions exploring awareness and use of women’s health services, awareness and understanding of WHHs and potential barriers and facilitators to using hubs and improvements to local services. The researchers explicitly asked participants about their awareness and use of their local hub model, and none had received care from a WHH. For three focus groups, consent was obtained from participants via signed consent forms returned via e-mail or in person, and in the fourth verbal consent was recorded. Focus-group participants received a £10 voucher as thanks, and community groups were also reimbursed for their time and/or premises use.

For most interviews, there was no prior relationship between the evaluator and participants, with the exception of interviews with the hub leader at each exemplar site, where more frequent contact and meetings to discuss the evaluation had occurred. Participants were provided with an information sheet which detailed reasons for the evaluation being conducted. Researchers’ personal goals or reasons for being involved in the evaluation were not disclosed.

Work package 3 sampling, participants and data collection

Survey analysis

Initial survey analysis was undertaken in July 2022 with 11 respondents, to aid selection of the 4 hubs for in-depth evaluation [see Work package 2 participants, sampling and data (exemplar hub evaluation)]. Analysis was updated in September 2022 (for the interim report) and January 2023 (for the final report). Survey data were exported into Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) for analysis. Descriptive statistics were computed for quantitative data, and free-text responses thematically analysed for reporting.

Analysis of interviews, focus groups and documents

Qualitative data from all interviews, focus groups and documents were analysed using a team-based rapid analysis approach, to deliver timely findings with methodological rigour. 97 Researchers reviewed each data item and summarised the main issues in the data into a ’summary template’ matrix in Microsoft Excel, with no formal coding of data. An initial summary template matrix was developed by the team following a review of the first four interview transcripts alongside the evaluation questions, with separate rows in the matrix to summarise different questions and findings. Each researcher summarised data they collected in a separate matrix (including data from their in-depth evaluation site, regional and national interviews). The research team systematically summarised each data item into the relevant summary template matrix, referencing the location of findings in the raw data and highlighting exemplar quotes and any key reflections and interpretation. Exemplar hub data were summarised by the lead researcher for each site. The summary template matrix structure was refined during the course of analysis, with regular discussion and reflection by the team (see Appendix 1). Analysis of summary template content was undertaken alongside analysis of other data sources and is described in the following section.

Triangulation across data sources

Triangulation of different methods can be conducted to ensure comprehensiveness and completeness of data collected, to explore convergences and discrepancies in different data sources and to check the credibility of findings. 98 Different sections of analysis were allocated to individual team members, informed by the evaluation questions and planned outputs. This was undertaken by four team members, all of whom were involved in data collection. Each researcher reviewed and summarised relevant data and analysis from across WPs, identifying and exploring similarities and differences between sources, participants and contexts. Summary reports were then reviewed, refined and combined by all five members of the research team. Participant validation of findings was not undertaken.

The relative importance of data sources varied according to the evaluation topic explored, and this is explained below. In order to consolidate the presentation of the approach to triangulation, topic areas and outputs are presented in a different order to the results sections of the main report.

Description, map and summary profiles of Women’s Health Hubs

Analysis drew predominantly on the descriptive data in the survey and desk research. Analysis was underpinned by the development of the WHH database, led by one of the evaluation team. All known hubs were entered into the database, and more were added as they were identified throughout the evaluation. Database fields related to hub characteristics and the evaluation and survey questions. The database was populated using quantitative and qualitative data gathered throughout the evaluation. The database was continuously reviewed to inform mapping and understanding of models, addressing gaps in information and adding detail where available. Hub leads were contacted directly to clarify details where possible. A map and description of WHHs were produced for an interim report in October 2022 and updated for the final report in early 2023. Mapping software was used to present the distribution of WHHs across the UK. 99 Tables, figures and narrative descriptions were produced to summarise the key features of models. Profiles of all identified hubs were produced at the end of the evaluation. Outputs were reviewed and refined by the whole evaluation team. Where possible, hub leaders also reviewed the profile of their service for accuracy and completeness.

Definitions and vision, models and approaches, influences on set-up, implementation and sustainability, advice for others, what is next for Women’s Health Hubs

Analysis drew predominantly on interview sources to develop detailed descriptions of experiences and perspectives. Scoping and national and regional interviews offered perspectives regarding the wider WHH policy and practice context, while exemplar hub sites provided more granular insights into the development of models in practice. The survey and desk research informed the more descriptive elements, and enabled interpretation of the representativeness of the exemplar hubs compared with the national picture.

Achievements, outcomes which are (or could be) used to assess impact and inequalities

Identification of current measures, outcomes and impacts and approaches to tackling inequalities drew predominantly on survey, desk research and documentary sources from WHH sites. Exploration of potential future measures, considerations and challenges was drawn from interview data, particularly from exemplar hubs.

Experiences and perspectives of women

Analysis was predominantly informed by data and analytical summaries of interviews and focus groups with women in the exemplar hub sites. Documents from desk research and exemplar hubs (e.g. patient feedback reports) and interviews with hub staff also provided some insights into women’s experience.

Development of the theory of change

A theory of change provides a framework to describe and illustrate the logic, assumptions and principles that link what a service or programme does, why and how it does it, with its intended outcomes and results. 100 Theories of change can be important in replicability and understanding what works and why, which is particularly important for initiatives and programmes which wish to scale up or expand, as is the case with WHHs. 101 They can take various forms, and Ghate100 describes how they usually include needs, inputs, activities, outcomes along with implementation outcomes and mechanisms of change.

We developed a theory of change for WHHs drawing on a framework from Ghate100 using Braithwaite et al.’s102 non-linear model, to begin to capture the complex processes that typify implementation. This was deemed appropriate given the emergent and heterogeneous nature of WHHs. The theory of change was developed across a series of evaluation team meetings and a workshop. Theories of change were sketched for each of the four in-depth evaluation sites by the lead researcher for each site, using the summary template matrix for the site to populate a Theory of Change template based on the Ghate framework. They were then reviewed collaboratively by the research team and consolidated into a single theory of change, also drawing on the wider evaluation data and analysis. At this stage, the theory of change is an initial iteration, which is evolving and can act as a tool to guide further implementation and evaluation.

Development of implications for policy, practice and research

Bringing together the findings, implications for policy and practice were identified, to support the commissioning, implementation and delivery of WHHs. Implications for future evaluation, particularly key areas of focus and considerations for any later work, were produced. The team held internal workshops in which findings were considered and implications suggested, which were also discussed with the Stakeholder Advisory Group prior to final refinement and development.

How do stakeholders define hubs?

Hubs were often described as a network of community services, where staff working within hubs work with other services in the local community (e.g. voluntary sector, non-healthcare statutory services, acute and community trusts). Interviewees described how WHHs may come from an existing primary care, sexual and reproductive and/or community gynae service by the addition or ‘bolting on’ of new treatments, or an adjustment of a way of working (e.g. bringing different staff together). Hubs were described as ‘a natural extension’ of existing services (EH3, internal interview) and a ‘refinement of the community gynae service’ (EH1, external interview).

Many interviewees indicated that WHHs should provide semi-specialised care beyond what primary care could usually be expected to deliver, but at a less specialised or complex level than secondary care provision. Hubs were therefore perceived as a middle ground between the GP and hospital service. In line with this, clinicians working across two sites defined hubs through their focus on non-surgical management and interventions.

I only found out about it through going to the doctor with an issue to do with the gynae area and then sort of got the vibe that it was something that was kind of like a middle-man between seeing a doctor [GP] and having to go to the hospital to the gynaecology clinic there.

EH1, patient interview

Most interviewees suggested that a hub was not necessarily a physical place, but a concept. Overall, they advocated a flexible approach to the physical setting, informed by pragmatism and a need to align with existing services and resources. To some, the defining feature of WHHs was the way care was integrated and provided (e.g. bringing different expertise together) rather than the physical building where care was provided. This aligns with the idea that WHHs may provide care virtually (i.e. using video conferencing or telephone appointments).

… So it doesn’t have to be that services and clinics are at one designated address or site within that PCN and that that has to be the set location, it’s more the concept of sharing skills within a patient population and improving that access, and hopefully less distance for patients to travel and not always needing to go to secondary care, but it’s not necessarily just one static venue in one location in a city nearby practices and PCNs, but it’s more the concept of sharing clinics, skills, resources amongst a patient population.

National interview

A common view was that hubs should take a broad and holistic approach to women’s care, and interviewees described an ambition to provide care in a way that minimises the need for multiple appointments, reducing fragmented care.

… whatever their concerns and issues are they could be sorted at one point exactly at the same visit, whatever we can … we try to cover everything for that woman, rather than separate appointments for heavy bleeding, separate for coil fitting, separate for smear.

EH4, internal interview

The intention for women to get the right care at the right time, from the most appropriate clinician(s), was shared, to avoid women being sent back and forth between different professionals and services. This approach to care was reflected in the frequent use of the term one-stop shop by different stakeholder groups (i.e. women using services, commissioners, staff working in hubs and surrounding services). For instance, women hoped for a one-stop shop to access expertise, advice or the opportunity for a ‘full MOT’ covering general health issues in addition to SRH.

… rather than a patient having to go to multiple places, multiple clinicians, it should be a one-stop shop. And the reality is across a life course, all of these things overlap and interreact, so it makes sense to put them all together.

EH4, external interview

Interviewees tended to use the term one-stop shop to describe the experience of using a service, rather than to define a particular model or draw boundaries around what a WHH should be. Other terms relating to models (e.g. hub and spoke) did not feature in interviews.

Interviewees suggested that WHHs should be comprehensive in their offer. For instance, that they should provide ‘… everything related to women’s health’ or a ‘complete package of care’ including menopause care, contraception, scans, heavy menstrual bleeding, pelvic pain and fertility.

What I feel a Women’s Health Hub is, is that whatever the problem if it is women’s health-related they can deal with it, whether it be the menopause clinic that they very kindly offer, which they can always self-refer, whether it be contraception, whether it be menstrual problems and irregularities, it’s a central point where all of these services can be accessed ….

EH4, external interview

Some women interviewed suggested that hubs should include maternity services, and a commissioner with a regional perspective described there being a ‘maternity corridor’ that does not link up well with other services. The scope of services that some interviewees felt should be included was very broad, spanning services beyond gynaecology and sexual health, such as services for mental health, bone health and cardiovascular risks. This was framed under the perspective that women are ‘… more than just their reproductive organs, but that is a good start’, as stated by a woman using hub services (EH4, internal interview). However, many interviewees suggested that WHHs should focus on core areas of women’s health such as LARC, at least in the early stages of hub development, and expand once the service is functioning well. Interviewees felt the care provided should be appropriate for women of all ages, with the phrases ‘cradle to the grave’ and ‘life-course approach’ arising in interviews. It was noted that some services may be on their way to being a WHH and that services may be on a continuum of a ‘hub way of working’, rather than this being binary status (hub/not a hub).

… I think that lots of people don’t think of that [WHH as on a continuum] because the ‘hub’ suggests that it’s everything, particularly in sexual and reproductive health … I would say three of those things [you need in order to be a hub] means you’re maybe bronze. Five, six, known as silver. Ten might be gold or you know ten plus two might then put you into a platinum.

Regional interview

Compared to women we interviewed, stakeholders working in the area of women’s health were more likely to draw boundaries around the type of care that should be provided by WHHs. It was acknowledged that there is, in practice, a limit to the number of services a hub can provide and that what is needed is strong integration with surrounding services and clear integrated pathways.

But you can’t have every service there … it [what is needed] may be education and advice and then a really good-quality referral so that they’re actually confident you’re referring to somebody who is going to be able to meet that need, where the waiting list is not, you know, two years/three years, etc., so that there’s a real understanding … you need really to make sure that it is well integrated and that the pathways do work, because otherwise you just end up pushing a problem somewhere else, you know, and everyone gets dissatisfied.

EH1, external interview

The key characteristics of WHHs described in this section are summarised by the following quote from a hub leader:

Women’s Health Hub is a concept. It’s about using what resources you’ve got. It’s about working in an existing infrastructure and sort of trying to reduce health inequalities, to improve access, and to link up a more holistic approach to women’s healthcare so that women aren’t having to go, for example, one place for contraception, another place for other services, but linking it up. It doesn’t have to be a new, purpose-built building. It doesn’t have to be a whole new infrastructure with a new manager and new lead.

EH2, internal interview

Variation in stakeholder definitions of Women’s Health Hubs

Most participants who discussed the topic described defining WHHs as a challenge. Definitions were described to be emerging conceptually.

… what is a women’s health hub? What does it absolutely precisely look like? I don’t think we’ve actually defined that yet. I think we bandy around that kind of term and it means, as many terms do, different things to different people.

Regional interview

A number of national stakeholders stated that through their discussions with colleagues and healthcare professionals, it was evident that there is a lack of a shared, clear understanding of what WHHs are and that people interpret the term hub differently and that consensus was needed.

… I was really concerned that people were looking, this is healthcare professionals, looking at this idea of a Women’s Health Hub very, very differently, you know, and there wasn’t a national understanding of what it was, which is why I think we’ve got to get a very easy to understand baseline offering out there that people can build on ….

National interview

This interviewee described confusion regarding whether WHHs are a ‘whole new commissioned piece’. National interviewees suggested that some services may determine that they are implementing a hub when in reality the care is not joined up or integrated. There was also concern that sites may be implementing a model that can be defined as a hub without realising it, and that women will not understand what a hub is, while the aim is for hubs to be a recognisable part of the NHS landscape in the future.

Many suggested that what a WHH means or looks like will be different for different people and will vary based on local resources and needs. The idea that there is no one-size-fits-all for WHHs was emphasised: for example, that WHHs will ‘… be slightly different in every PCN’ (EH1, internal interview). Consequently, a flexible definition was suggested to be required to fit models with local needs and resources.

I think there’s not always one size fits all, I think necessity is the mother of invention and people will, where there’s a bit of tenacity and passion, enthusiasm and skill and determination, I think services will crop up looking slightly different in different regions.

National interview

Despite the apparent acceptance of variation, some national stakeholders suggested that in practice most people working in this field had a shared vision. These interviewees described how differences manifested themselves in the way hubs are designed and deliver care.

A number of other defining hub characteristics were described by participants, but they were given less priority. They were that WHHs should:

• Be women-centred and provide non-judgemental and friendly support.

• Be co-produced, so it is not assumed what would work for local women.

• Consider offering support with social issues (e.g. money and housing) to prevent health issues occurring and worsening.

• Sit within a wider movement to improve and raise awareness on women’s health.

Some participants discussed how hubs align with ongoing policies and priorities, including the establishment of ICSs, the NHS Long-Term Plan, multidisciplinary working, moving care closer to home and tackling inequalities. Participants did not report any current links between WHHs and other hub models in the NHS, for example maternity, mental health and family hubs.

There was broad consensus across interviewees on the following:

• There is no one-size-fits all and that WHHs will vary based on local needs and resources with a need for flexibility in definitions.

• Women’s Health Hubs sit within a network of services and should aim to link with and integrate across organisations and sectors.

• Women’s Health Hubs are ’semi-specialised’, providing care that sits between primary and secondary services.

• Women’s Health Hubs should be comprehensive in the services they offer and minimise the need for multiple appointments, providing ‘holistic’ care.

• Women’s Health Hubs do not have to be a completely new service.

Interviewees highlighted that there are confusion and variation in definitions. Perspectives shared here were broadly in alignment with our working definition (see Introduction, ‘a working definition for the evaluation’).

Why have Women’s Health Hubs been implemented?

A wide range of reasons were described as driving hub implementation. The most commonly cited was to bridge the gap between primary and secondary care. WHHs were set up to improve access to appropriate and timely care in the community in a way that reduces inequalities, waiting times, inappropriate referrals and overall pressure on primary and secondary care.

… I was just really, really passionate that all women should have a choice about accessing LARC in primary care … and that all women should have that choice, not just the women who happened to have a LARC fitter in their own practice.

EH2, internal interview

Some interviewees described additional drivers that were not specific to WHHs, including COVID-19 care backlogs and an NHS agenda to design services so that existing resources are utilised more effectively to cope with increasing demand and budget pressures. Others described a wider movement towards integrated care as a justification for WHHs, for instance to provide more joined-up care pathways and bring people with skills and ideas together for collaborative working.

The impetus for the implementation of a WHH in some sites was an observation of unmet need, postcode lotteries, or service gaps and inequalities in access and quality of care. For example, the need to ensure that young women, women living in deprived areas and women with specific cultural needs are appropriately represented and served. This includes the observation of unwarranted variations, for example in referral rates and triage processes across PCNs and practices, such as GP referral rates to community and secondary care services.

In all exemplar sites, implementation was driven by individuals with a passion for and expertise in women’s health. For example, in one hub the lead was keen to utilise LARC training she had undertaken, and to offer this service to neighbouring practices without LARC fitters. Hub implementation was also influenced ‘top down’, by local, regional or national programmes and initiatives: for example, CCG programmes to transform outpatient services and reduce secondary care waiting lists, ICB agendas to provide joined-up, patient-centred care, and PCNs prioritising sexual health. In one site, the clinical lead was directly approached by their CCG and asked to develop a hub in line with aspirations to increase availability of community-based care. Participants also cited wider societal and professional influences on implementation, including an increase in female GPs (and thus awareness and motivation to improve women’s health), and a recent rise in demand by women seeking menopause support following media campaigns.

What do current Women’s Health Hubs models aim to achieve?

Hubs were described as aiming to achieve a broad range of outcomes simultaneously and it was often not clear which aims were the priority. However, in the survey, all hubs (n = 14) selected the following aims: to improve choice for women, reduce waiting times, reduce the number of appointments needed for a problem and/or reduce use of secondary care.

Overall, aims that were described in the survey and interviews were often about improvements in the following:

1. The type of services available so that care feels holistic (e.g. to enable women to have multiple SRH needs met in a single visit, and bring together a range of services).

2. The way services are organised, and the location/venue in which care is provided (e.g. to reduce inappropriate referrals to secondary care, provide appropriate expertise and care more locally, and provide more joined-up/integrated care across services and sectors).

3. Access to care (e.g. to decrease barriers and waiting times, expand the reach and scope of services, maximise access and convenience).

4. Reducing inequalities (e.g. ensure fairer access to care, reduce variation in access and quality across GP practices and regions).

5. Quality of care (e.g. standardisation and consistency of care, improve patient outcomes, improve referral processes, early intervention, better resolution of symptoms).

6. Women’s experience (e.g. improved listening to and empowering of women to have a voice in their care, enable more proactivity and self-management of symptoms, ensure women receive help earlier, have fewer appointments and examinations, a reduction in travel time and more choice, e.g. over venues and times).

The interviews in the exemplar hubs highlighted the differences in specificity of hub aims. While some had very specific and targeted objectives (e.g. to support the delivery of the 18-week waiting time target for secondary care), others were broader and more high level. Overall, hub objectives appeared to be more high level: for instance, stating the aim of reducing referrals to secondary care without specifying a target. The broad aims of WHHs were summarised succinctly by a survey respondent:

To bridge the gap between primary and secondary care and allow collaborative working and learning between GPs and gynaecology consultants. To allow women to receive the right treatment in the right place at the right time using our triage model and utilise community clinics outside of [gynaecology service] by using a single point of access. Help reduce backlog in secondary care.

Survey respondent

Key features of women’s health hubs

Table 11 summarises the key features of the 17 hubs. The majority were described by respondents as currently operational with plans to expand. This is also reflected by launch dates, with some having only launched in the past 3 years, with some hubs relatively new and in set-up and/or starting to function at the time of the COVID-19 pandemic.

The table highlights the varied nomenclature for local hubs. Despite meeting our definition of a WHH, most hubs did not refer to themselves as a WHH, or only did so informally (e.g. not in any documentation). Other terms used instead of ‘hub’ included ‘community gynaecology service’ or ‘clinics’. Only three locally referred to the service as a ‘hub’.

Respondents providing information on the population served by their hub (N = 12) offered services to all women in the area, not just to specific groups of women. However, women usually had to be registered with a GP in a specific location to access hub services. Some hubs aspired to expand the geographical area the hub covered.

Hub delivery models

Clinical offer

Figure 2 summarises the services offered by hubs. All 17 hubs responding to the survey question reported that LARCs were offered for gynaecological reasons. Other frequently reported services include LARCs for contraception (N = 15, all except hubs F and H), and 16 hubs offered heavy menstrual bleeding consultation (all except hub N) and treatment and menopause care (all except hub K). No hub reported offering pelvic physiotherapy or termination of pregnancy services. While seven hubs reported offering women’s health counselling/psychology, this was often limited to psychosexual counselling rather than broader mental health support. As mentioned earlier, most respondents reported launching their hub with a limited range of services before expanding the offer, or reported aspirations to expand in this way. The initial service offer in part depended on the skills and interests of those leading hub development (e.g. leaders with expertise and interest in LARC may initially focus the hub offer on this).

FIGURE 2.

Services offered (N = 17).

Four hubs offered services in the evening and four at weekends (Table 13). While one of the main objectives was to improve access to care, most hubs only offered services during core hours, though some respondents reported aspirations to offer out-of-hours services in the future. A range of appointment formats were offered (Table 13), with 15 hubs offering appointments face to face and by telephone, with 2 hubs also offering online/video appointments. Only one offered online group consultations.

TABLE 13 - Hub appointment availability and formats (N = 17)

Out-of-hours provision	Number of hubs (N = 17)
Appointment format	Number of hubs (N = 15)
Evenings	5 (hubs A, D, J, L, O)
Weekends	5 (hubs A, B, J, L, O)
None	11 (hubs C, E–I, K, M, N, P, Q)
Face to face	15 (hubs A–F, H, J–Q)
Telephone	15 (hubs A–F, H, J–Q)
Online/video	2 (hubs E, M)
Group video consultations	1 (hub F)

Hubs were often seen as offering services that were more complex than a regular GP could support, but not as complex as specialist secondary care services are trained and equipped to manage. Participants described how upskilling hub staff could widen the offer and manage more patient care outside of secondary care. However, some reported situations where hubs may offer the same services as ’standard’ primary care for a particular reason, to meet local needs or due to local context. For example, women who prefer to see a female clinician may visit a hub where this is not available in primary care.

… it’s [ultrasound scanning] something I’d really love to upskill in and it would enable us to, for example, do more with our core clinic, so we could deal with lost [coil] threads and more complex/deeper procedures where we’d normally refer to secondary care service, but hopefully with those skills under our belt and the right support, and agreed competencies, oversight and pathways and dialogue with our secondary care consultants, there is arguably some more things that we can begin to take on in primary care.

Scoping interview

While most services were offered as one-to-one consultations with a clinician, some hubs also offered support via online or in-person engagement and education events with women or clinicians. These may be focused on, for example, menopause, contraception and fertility, or reaching out to specific vulnerable groups. This was described as of equal importance to one-to-one consultations, as educational events can support women to self-manage, reducing the number of appointments in primary care.

Many interviewees highlighted the importance of avoiding an overly prescriptive, top-down specification of the service offer in hubs, to allow flexibility to tailor to local needs.

It depends on their population needs …. With a very old population maybe you want to start concentrating on pessary care, a younger population you might be wanting to sort of look at early menopause care. I think people have got to tailor make it to their population, for their particular needs ….

Scoping interview

However, others noted some degree of standardised, baseline service offer is still needed in addition to tailoring the service to support sharing of learning, avoid reinvention of the wheel and ensure equitable provision (discussed further in Influences on hub set-up, implementation and sustainability).

What I’m quite concerned about is that we’ve done it in the past, we’ve gone off and done lots of different things, said every area’s got to sort out what they need, but actually you need a baseline offer, so that it is similar across the county, even if you can tweak it, because otherwise everybody’s trying to embed this in every corner of the UK and it’s such a waste of energy.

Scoping interview

While a frequently stated objective for many hubs was to provide holistic care, in reality the focus was on core sexual and reproductive health needs. There was minimal discussion of wider issues, such as mental health (beyond psychosexual health), non-gynaecological conditions (e.g. heart disease) or social well-being. However, many stakeholders suggested that hubs should adopt a wider holistic view of care and there was one account of a hub currently in set-up which had included weight-management services in its design.

Leadership models

Throughout the evaluation, we explored leadership roles, and perspectives of who should be involved in leadership. While we recognise that there are multiple types of formal leadership (e.g. clinical, operational, commissioning), as well as differences between leadership and management, most participants did not make this distinction in the interviews. In many cases, leadership and management roles were blended. There was also a focus on expert leadership (i.e. the ability to lead as the individual(s) have valuable knowledge, expertise and/or qualifications) by individuals with a specific interest and passion for women’s health (see Influences on hub set-up, implementation and sustainability). Interviewees described roles and organisations involved in hub leadership, although this often involved collaborative partnership working, and did not necessarily involve formalised leadership roles, responsibilities or accountability. Participants also described different functions of leadership, for example leadership of hub implementation, or day-to-day clinical leadership of hub teams.

Survey respondents were asked to state which role(s) were driving the establishment of the hub (Table 14). In most cases, a single individual was reported to be performing this role, usually GPs with a special interest in women’s health, with SRH consultants, secondary care gynaecologists, local authority commissioners and CCG representatives also cited. In four hubs, multiple roles were involved in driving hub establishment (hubs A, H, K, M).

All hubs were clinically led by doctors, over half by GPs (Table 14), with SRH and gynaecology consultants in the remainder. Only one hub reported a difference in the role that was driving establishment of the hub and who was clinically leading it (hub N, driven by local authority commissioner and clinically led by a GP). Many hubs described a governance structure in place to oversee the hub implementation, activity and budget, to whom the clinical lead was accountable (see Implementation approaches for further detail).

There were various roles and responsibilities held by hub clinical leads, which included:

• Responsibility for hub governance and management (reporting and accountable to a governance board).

• Designing patient pathways.

• Developing and maintaining relationships with other stakeholders, for example secondary care, PCN leads

• Quality assurance, overseeing of staff training, ensuring appropriate guidelines/standard operating procedures were in place.

• Identifying issues and areas for improvement.

Interviewees shared opinions regarding the advantages and disadvantages of hubs being clinically led by secondary care consultants and GPs (Box 9), and there was some discordance among participants, with a tendency to favour their local model. Some suggested that hubs could be clinically led by GPs alongside, or with clinical support/oversight from, secondary care or community gynaecology consultants. Others expressed concerns about GP-led models (see Box 9), preferring consultant gynaecology or SRH consultant clinical leadership due to their specialist training to manage more complex issues.

Having consultant input I think is really important though because there are some GPs who can do a lot, but what we want is to be able to manage the patients as much as possible within that place. If you want to do that, that’s where you need SRH consultant leadership, but you don’t need them to be delivering a lot of the work, because a lot of GPs are really well placed to do some of it.

EH4, internal interview

Others reported that non-GP primary care roles such as nurses could offer some aspects of clinical leadership in hubs:

It [hub leadership] is primary care as in the bigger multidisciplinary team. And in one area it might be led by a nurse to start with or even a pharmacist or a paramedic or a GP, but then … it should grow from there to get a bigger team.

EH3, internal interview

In addition to clinical leadership roles, interviewees also commented on the importance of having commissioner involvement in hub strategic leadership to establish models and unlock resource. Local authority representation in the collaborative hub commissioning and leadership arrangements was cited often, as councils are pivotal organisations as leads for sexual health commissioning. However, it was suggested that hubs should not be solely local authority-led as the NHS was a key stakeholder.

… I would really question the extent to which local authorities are both best placed to and really responsible for taking some of the lead for contraception in primary care, I think the NHS has always been slightly missing on this agenda ….

Regional interview

Organisations involved in hub design and delivery

Varied organisations were involved in designing and delivering hubs, indicating the varied population footprints a hub can adopt. For example, some hubs served women across one or more ICS/CCG footprints (e.g. hub E). Others served one or more PCN areas (e.g. hubs I and N) or GP Federations (e.g. all Northern Ireland hubs). Most often survey respondents described the involvement of GP practices in both providing hub services and/or referring women to the hub (mentioned by all 14 responding hubs) (Table 15). Involved in over half of hubs were local authorities, NHS acute trusts, PCNs and CCGs/ICBs.

Interviews explored how organisations were involved in hub design and delivery. CCGs and local authorities had been involved in the commissioning and designing of the hubs, including by supporting identification of gaps in existing services, and mapping pathways. Secondary care providers often (but not always) accepted referrals from hubs and supported hubs in other ways, for example hub staff attending hospital gynaecology meetings, gynaecologists providing clinical advice for complex women and contributing to communication materials and guidelines.

… so when there is a little bit of an overlap in terms of when does something have to go to secondary care, when can it be handled in primary care, I think that relationship is very precious to ask for help when needed, to check we’re all being careful to abide by the right levels of competencies and qualifications, and if we are looking to upskill that we’ve got the support of secondary care with that.

Scoping interview

Pharmaceutical companies providing LARC devices had also provided input. They provided resource and expertise to support the set-up of hubs, including modelling costs and outcomes for LARC services, designing guidance, tools and pathways, and training clinical staff.

Funding, commissioning and contracting models

Venue of hub services

From the survey and interviews, there was wide variation in the number of venues provided by individual hubs, ranging between 1 and 9. Most were offered in GP practices, with some also delivering services in a hospital setting, sexual health clinic, community NHS trust or pharmacy-based clinic (Table 18). Activities such as engagement and education events were held online, usually delivered by primary care hub staff. From the survey, six hubs provided information on the number of clinics offered, which varied substantially (between 8 and 56 clinics per month).

Challenges were described in co-ordinating and standardising hub services offered across multiple PCNs and/or GP practices, as each had their own set of standard practices. While this can offer advantages (e.g. access to a broader range of clinical roles in different GP practices/PCNs), it does require separate discussions and solutions to manage. GP federations may also offer support by acting as an interface between GPs and secondary care and subcontracting with PCN GP leads.

… all the GPs are independent and PCNs hopefully bring them together and it makes some joint decisions, but largely they work independently and so the advantage of having an overview is that you can kind of try and bring all those things together and have a sort of bird’s eye view ….

EH1, internal interview

Implementation approaches

Implementation processes

Participants reported that hub implementation occurred in stages, beginning with mapping existing services and gaps, designing a hub model to address these gaps, securing funding/buy-in and setting up the hub. These stages will be briefly outlined and they are summarised in Figure 3. Where data were available on implementation processes, the stages outlined below occur in most hubs in some form.

FIGURE 3.

Summary of WHH implementation processes.

Existing services and gaps were mapped in some hubs to inform the design and scope of the hub model. This included, for example, reviewing referral numbers and reasons for referral to secondary care to identify how much could be moved into the community, mapping skills mix/gaps of local GPs, identifying gaps in services (e.g. low LARC uptake) and mapping costs of existing services. These activities were often performed in collaboration across organisations (e.g. GPs, commissioners, secondary care), which was reported to support the development of a shared hub vision and strategy.

And so an audit was done to see, out of all the GP referrals in the [area name], how many could have been managed outside the hospital, if you had the right kind of skill, to manage it. That’s where it started. Stakeholders were involved. I was involved because I was a community gynaecology consultant. Hospital consultants were involved and GPs were involved.

EH4, internal interview

After mapping existing services and gaps, sites then moved on to scoping and designing their hub model: for example, deciding which services to offer, mapping care/referral pathways and modelling costs and tariffs for potential hub services. Again, this process often involved a range of stakeholders and organisations (e.g. GPs, secondary care, commissioners, pharmaceutical companies). This planning was then used to develop a business case to secure funding and outline anticipated impacts of the hub (e.g. cost savings, reduced waiting lists) to support buy-in from commissioners and potential providers (e.g. GPs). Often this was initial funding to develop a proof-of-concept pilot hub, with additional buy-in and identification of funding required at a later stage to move to an established service (see next section).

The next thing that was done was a business case, to look at … basically two things; saving money and reducing waiting times. And then the appropriateness of what should be seen. And then the business case included … what would they cost? How would you set that up? What was the administrative structure?

EH4, internal interview

Once the early design phase was completed and funding and buy-in had been secured, hubs could then move towards implementation activities, which included:

• Setting up IT systems and addressing IT barriers where they existed, for example sharing of data/systems.

• Identifying training needs and recruiting staff with required expertise/qualifications.

• Identifying facilities, physical space, necessary resources/services (e.g. testing services, implants/coils) and equipment (e.g. gynaecology couches).

• Defining and gathering intelligence to measure impacts.

Some hubs set up a steering or strategy group to oversee the implementation and delivery of the hub. As with the early design phase, this often involved stakeholders across multiple organisations (e.g. primary care staff, secondary care staff, commissioners, public/patients). These groups undertook varied activities, including reviewing hub activity, discussing plans for hub growth, inputting into patient pathway design and risk management.

Respondents from only six hubs in the survey reported having patient/public involvement in hub design and delivery (hubs B, F, H, L, M, O). This took the form of, for example, members of the public on the hub steering/strategy group, hosting women’s engagement events/public consultations and incorporating patient feedback into hub service design. In nine hubs, respondents reported that there had been no involvement of patients/public in hub design and delivery. Involvement of women in the design and delivery of WHHs was not frequently discussed. Two exemplar sites reported activities, including exploring local transport, accessibility and inequalities with a patient committee, past consultation about potential hub changes, a patient engagement subgroup chaired by Healthwatch with user representatives, and user involvement in developing hub information. One interviewee described the importance of working bottom-up and involving women:

You could impose something very top-down, you could say ‘this is what we’re going to do’, … but then I think we will lose that kind of population neighbourhood everybody onboard everybody – including women …. So I really believe that it has to be a much more bottom-up thing.

EH1, internal interview

The survey also provided other examples of involvement across different UK hub sites, with six hubs providing further information, including:

• A local group commissioned by the Public Health Team to undertake both online and face-to-face consultations with local women, with a reference group being supported.

• A patient engagement event, supported by local charities with an interest in women’s health.

• The involvement of Healthwatch, in terms of both gathering feedback and their inclusion on a hub steering group.

Some sites also reported collecting patient feedback, which one interviewee described was used to improve services via a ‘You said, we did’ approach, with changes made in response to patient comments, keeping women involved in service development. Respondents from nine other hubs reported that there had been no involvement of women in hub design and delivery.

Approaches to integration

As outlined in Chapter 2, there are different dimensions of integration. We identified multiple integration frameworks and have used concepts from three frameworks to describe five types of integration. We did not include specific questions about integration in the survey. However, some questions did provide insights on aspects of integrated care planning and provision, such as commissioning arrangements between organisations and sectors, organisations/structures (e.g. leadership and organisations that form the hub) and services offered, all described earlier in this chapter.

In Table 19, we provide examples from the four exemplar hubs of how they have implemented different aspects of integrated care.

TABLE 19 - Examples of different forms of integration identified in the exemplar hubs

Note

See Chapter 2 for further information on integration frameworks and definitions of these categories (no examples of system integration were identified).

Integration type	Examples
Structural/organisational	Steering Committees set up for hub design, development and oversight Set up of interoperable IT and administrative systems and functions Linked local clinical partnerships (e.g. PCNs or GP Federations) Utilisation of existing linked local partnerships/integrated policies and models (e.g. PCNs or GP Federations) Setting up MDTs Joint-commissioning arrangements and contracts Colocation of staff Passionate and motivated leadership
Functional/administrative	Interoperable IT and administrative systems and functions (e.g. joint/central booking systems; interpractice referrals) Jointly developed documentation (e.g. business case, service specification)
Clinical/coordination and integration of care	Formalised/improved referral and care pathways created across organisations Extended clinical roles through training (e.g. GPs with a special interest) Wider service offer (often in a single appointment, e.g. cervical screening and coil fitting) Hub staff able to review patient medical records across primary, community and secondary to support provision of care New professional roles
Interpersonal	Co-operation and collaboration in overcoming barriers Regular communication (e.g. through MDT meetings or when colocated) Cross-organisational collaboration and co-operation in the design, development and oversight of hubs Engagement from relevant people including commissioners across organisations, sectors and levels of the healthcare system Passionate and motivated leadership with cross-organisational relationships Hub GPs having autonomy over their clinics and patient care, while also being able to seek advice (from other hub staff or hospital consultants) when needed
Normative	Shared vision and goals at team level, between individuals at multiple organisations and services involved and nationally supported by a sense of urgency and prioritisation of women’s health Time spent developing strong, trusting relationships across organisations Motivated and enthusiastic hub leads Wider hub staff (clinical and non-clinical) motivated and enthusiastic to deliver the service
Systems/whole systems	No examples were identified of integration across healthcare systems (i.e. ICS level). However, some hubs were working across PCNs or CCGs.

Integration activities overlap in places with the implementation strategies described in Figure 4 (e.g. setting up a steering committee and developing a business case). This is because when these activities are undertaken in collaboration between organisations and sectors, they can be perceived as examples of integrated care planning and provision. Many of the examples of integration relate to the set-up and planning of hubs under ’structural/organisational’ integration. Understanding this stage was a key aim of the evaluation. Examples include MDTs (EH1, EH4) and steering committees, which facilitated collaboration and cooperation in the design, development and oversight of hubs (interpersonal).

FIGURE 4.

Theory of change: how WHHs might work – cyclical, incremental growth. LES, Locally Enhanced Service; PH, Public Health.

As WHHs were often conceived from the motivation of passionate local leaders, normative integration was common, in the form of shared values developed through the skilled communication and networks of hub leads. Another common type of integration was the integration of back-office or administrative functions to enable the successful day-to-day functioning of a hub (e.g. for booking/referring, testing and prescribing) and the ability to provide a wider clinical offer. Challenges to integrated working were common, as were proposed solutions. These are described in the Influences on hub set-up, implementation and sustainability section.

Workforce models and approaches

Workforce varied across models. The most frequently reported roles were GPs with special interest in women’s health and administrators (Table 20).

Some interviewees suggested that there are opportunities for greater involvement of other staff roles, particularly related to offering a more holistic service that takes into account the wider aspects of women’s health (Box 11).

Some exemplar site interviewees discussed the advantage of having GPs with special interest in women’s health delivering hub services (direct care, distinct from leading the hubs). First, they offer more specific expertise than a GP without special interest, enabling the hub to offer services that are more advanced than a routine GP appointment. Some also reported that primary care staff are better able to provide care in a more holistic manner (e.g. longer appointment times to allow time for discussion with the woman and considering the woman as a whole), where secondary care may be more focused on episodic care.

Because it’s run by GPs, I think that we offer a very holistic service to our patients. So we give them time and we’re familiar with looking at the whole because whilst a woman might present with a gynae problem it’s influenced by a lot of things including mental health, abdominal problems as well as just the gynae presenting problem.

EH3, internal interview

It was also suggested that GPs with special interest may offer different expertise than some secondary care professionals who may be involved in women’s care, as they straddle both generalist primary care and specialist women’s health practice. Respondents in one exemplar hub site suggested that primary care was a more acceptable environment and that pathways were more flexible than hospital, for example psychosexual counselling can be offered on a long-term basis over multiple sessions, which would not be possible for a hospital waiting-list-based service. In addition, primary care-based hub staff suggested that hospital consultants would find it more difficult to slot women in if they need to be seen or rearrange appointments themselves, which was possible in primary care.

But I think it’s [psychosexual counselling] much more amenable or much more to be in the intimate environment of a GP surgery where you can see people. And they might need to be seen over several years, and that doesn’t really fit into a hospital waiting list follow-up type service. Because [a primary care clinician] can say ‘I need to see this lady in six weeks’ and then she can jiggle things around to fit that in.

EH3, external interview

Training, education and competency requirements

Theory of change for hub implementation

As described in Chapter 3, we developed a theory of change (Figure 4) for WHH implementation based on the structure outlined in the paper by Ghate et al. 100 It is important to highlight that visual representations cannot fully illustrate the complexity of health system change, and we do not intend to suggest that the implementation process for WHHs is linear. The theory of change uses the findings from the evaluation to illustrate broadly how WHH implementation could work, rather than aligning with any specific model we explored, and no model demonstrated every characteristic in the theory. The outcomes listed represent the aims of WHHs, rather than what we currently have strong evidence to show. The unintended consequences (including any additional costs) and assumptions regarding what hubs can achieve have not yet been measured or tested. This theory also does not capture wider societal or long-term impacts, for example societal benefits from reduced unplanned pregnancies. The theory focuses on women’s health only in terms of reproductive and sexual health as this is the current focus of the hubs identified in the evaluation.

National policy and practice context

Many national-level challenges were described, including change in government and policy teams, the COVID-19 backlog and competing health service priorities, rising demand for SRH services (particularly menopause care), and the availability and cost of devices such as IUDs. However, some hubs reported how some apparent challenges were in fact drivers of hub implementation (Box 13). For instance, the need to innovate and reduce COVID-19 backlogs and secondary care pressures helped to make the case for WHHs.

A lack of clarity about where the overall responsibility lies for WHHs was described, with specific designated leadership for women’s health having been absent from national, regional and ICS portfolios, which has since been addressed at the national level with the appointment of the Women’s Health Ambassador and team. A regional interviewee described how currently ‘… it’s sort of everybody’s responsibility and nobody’s to get it going’. WHHs explored in this evaluation have been designed and implemented before the Women’s Health Strategy was published. They have been developed from the ‘bottom up’ by local leaders in a small proportion of health systems in England, rather than ‘top down’ and nationally directed and mandated. Interviewees described this local, bottom-up approach as having enabled innovation, rapidity and responsiveness to local needs and priorities. However, there was tension between standardisation and flexibility in hub implementation, with stakeholders also reporting a lack of standardisation and a desire for greater national support and direction. For example, an interviewee commented that conversations were needed around shifting resources across budgets with ‘the people that matter’ (EH2, internal interview).

Several interviewees highlighted that support at a national policy level was helpful in driving change and developing and embedding WHHs. Overall, however, participants reported a lack of associated national funding or guidance for the policy (at the time of fieldwork) and many participants described the need for a regional and national, cohesive programme for women’s health beyond maternity care, which included oversight, drive, infrastructure and support. This was described as hindering progress, particularly in terms of overcoming commissioning barriers. A need was also reported for regional and national champions, including in NHS England, to expedite hub implementation.

… and it’s always struck me that NHS England, they don’t have a lead for contraception … without sort of leadership at a national level sort of filtering down, it’s always going to be a struggle getting buy in on some of these things.

Regional interview

The publication of the Women’s Health Strategy in 202212 had started to address the gaps in national guidance by recommending the setting up of hubs, and participants welcomed the new focus and prioritisation of women’s health and the newly appointed role of a Women’s Health Ambassador. While the importance of a national drive and, to varying extents, standardisation of approach was described by participants, many expressed concerns about this jeopardising the ability of hubs to develop out of, and respond to, local priorities, needs and resources.

I’d love it if there was more infrastructure there and I think it just slowly grows over time. But I think the completely alternative option is your top-down model, and most of the time, particularly – I think it still works better to build bottom up, because you know you’re working with what you’ve got. You know you’ve got your providers actually saying ‘This is the real-life challenges. This is what we can and what we can’t do. This is the capacity we’ve got’. ‘Oh well that IT idea won’t work because this system won’t speak to this system’.

EH2, internal interview

Local context and variation

Problems and solutions to commissioning challenges are often context-specific and locally determined. Variations in how different commissioners and providers work, the needs of local populations and local capacity for implementing WHHs were described as impacting hub implementation (Box 14). These variations can appear across regions, PCNs, local authorities and GP practices, and one participant commented that implementing a hub model across a large area with a greater number of organisations meant that there would be more variation to contend with. Variations in existing service provision, access and quality were also described and this lack of standardisation was said to hinder hub implementation, integration and widespread improvements across a whole area. It was also highlighted that the strength of existing women’s health services in an area may determine the need for a WHH.

Within our network there are four surgeries and within the four surgeries, three of them were already providing coils and implants so just from our perspective … we didn’t feel like it was worth doing all that extra admin and you know trying to get funding and everything for something that we’re already doing … it just so happens there’s a lot of female GPs who are interested in contraception so the need wasn’t as big in our area for the hub model.

EH2, external interview

Interviewees and survey respondents frequently described the importance of building relationships with ‘key people in each part of [the] system’ (EH4, external interview), particularly primary and secondary care, and between GPs and consultants. However, some experiences of difficulties working with individuals across the healthcare system were described. At the stage of setting up a hub, some interviewees described apprehension from local stakeholders regarding the changing approach to women’s health, and how this would impact on their own services. In models where hubs were providing services usually delivered in primary care, fear was expressed that GPs would be de-skilled, or that work and funds would be diverted away from the GP. In hub models undertaking procedures usually delivered in secondary care, concerns were raised about a potential loss of resources from secondary care, and about the clinical safety and quality of care outside hospital settings.

However, such issues were not reported to have persisted following hub set-up. For example, one site reported that clear communication and demonstration of the hub team’s qualifications had improved perceptions in the local area. Multidisciplinary engagement meetings were described as beneficial in advertising hubs and attracting interest as well as reassuring staff in surrounding services who may be concerned about the impact of WHHs on their service. This may be difficult where a hub is aiming to provide care across a large number of PCNs or local authorities.

… the consultants at the Royal [name of place] were rather apprehensive about the service and worried about how much work we would take over and they were suspicious or were concerned about what our role would be and how they would work with us, but over the years we’ve managed to forge really good relationships with the clinical team ….

EH3, internal interview

External stakeholder characteristics and behaviours were described as influencing hub implementation. For example, staff from different organisations who were willing to work together to resolve issues, and open to learning about ways to do things better (e.g. by improving the appropriateness of referral pathways), were said to be crucial in making progress. Motivation and an interest in women’s health were also acknowledged as key.

… they need to want to do it, you know, the nurse, the doctor needs to be interested enough in sexual health to want to be a sexual health specialist, there are so many calls from doctors to be specialists in other things ….

EH1, external interview

Funding and commissioning for Women’s Health Hubs

A range of costs were associated with setting up and implementing hubs, and sites reported that considerable work was needed to identify and access funding in their areas. Although sites had been able to access funds for some activities, there were often constraints around how funding could be used, and additional funds for increased activity could be difficult to access. Commissioning challenges were prolific, and participants across all exemplar sites described funding as a barrier to WHHs to varying degrees and described pressures on funding, with reduced spending in areas such as public health, and resources not matching increasing demand in other areas (Box 15).

Public Health has had such phenomenal cuts and the NHS has had budget increases that are not even kept in line with inflation and/or growth. The whole sector has been in a prolonged period of efficiency savings, cuts, whatever you want, however you want to describe it ….

Regional interview

Lack of new funding or cuts and the wider climate of austerity were identified as hindering delivery across hub sites. Impacts of funding constraints included reductions in the range of services offered, reduced training offered to external staff, less community engagement, threats to financial viability, gaps in staffing (e.g. for planning and coordination of implementation) and less opportunity to grow the service (e.g. increasing the volume of clinics and venues). In interviews conducted before the announcement of national funding to support hub development,22 a few interviewees noted that funding would be needed for nation-wide WHH roll-out and provided examples of how the funds could be spent.

If [the strategy] came with some money, that would enable me to be able to get that £30 uplift for the coil fitting that’s going to make it doable, that would then start the process rolling.

Regional interview

Examples were shared across sites of motivated leaders utilising existing resources and being innovative in the absence of dedicated funding. However, it was suggested that it is unlikely that everyone will have the motivation or resources to do this.

Some people haven’t got the capacity, and I think that’s going to be a big player, big factor, as to whether people have got the time to really devote to it to get it properly sorted.

EH2, internal interview

Resources

A range of resources were seen as essential in setting up, running and improving WHHs. These include clinical and administrative spaces, equipment and IT infrastructure and systems. Identifying resources created organisational and logistical challenges and involved considerable work, which was described as time-consuming, including arranging meetings, acquiring space, booking rooms, ordering equipment and communicating with administrators (Box 16). A practice manager commented on the need for strong infrastructure to support hub implementation.

If you try and deliver that service on a faulty or on a fragile infrastructure, you know what’s going to happen. It is going to fail. Now with the best will in the world, even if you’ve got the most committed people, if you don’t give them the tools to do the job, they will do their best but that will not be good enough.

EH1, external interview

Workforce

Human resources, specifically, strong leadership and a clinical and administrative hub team were described as key. In this section, we explore accounts of workforce requirements and the main challenges to obtaining and retaining a hub with adequate capacity and the right skills (Box 17).

What is measured, and what has been achieved

Through the survey, fieldwork and documentary analysis the evaluation team identified summary statistics from sites across the country (not restricted to in-depth evaluation sites), usually in the form of frequency data. These data evidenced how hubs were providing access and care for hundreds of women in their local health systems. Variation in measures and numerators and unknown denominators in the minimal available data prevent meaningful comparison and evaluation of the relative benefits of different models, so this is not presented in this report. Accurate and consistent reporting will be important to enable in-depth evaluation and understanding of relative performance and costs of models in future. However, some selected meaningful summary statistics were available, in particular:

• Onward referral rates to secondary care gynaecology ranged from 5% to 14% (Birmingham, Guildford and Waverley, Manchester), highlighting achievements in treating women in hubs the community and reducing gynaecology waiting lists. Variations may reflect differences in the women accessing services in these areas, or in the services offered.

• Triage times and waiting times varied but were short (Birmingham, Guildford and Waverley, Leicester), with triage within days and appointments within a few weeks or less, evidencing how models are improving access in a context where gynaecology waiting lists are high.

• One site (Hackney) reported a 14% reduction in secondary care gynaecology referrals by local PCN GPs following hub implementation, which may indicate a shift in referral patterns towards the hub, and/or increasing routine management of women’s health issues in primary care without onward referral, due to increased knowledge and confidence in local GPs.

• One site (Liverpool) reported an 8.5% increase in LARC fitting rates in the local population following hub implementation, evidencing a real population-level impact on local women in a context where access to LARCs was a key local challenge.

While current measures prevented meaningful comparison, through interviews and documentary analysis we identified diverse performance measures for WHHs, reflecting the locally driven design and implementation of these models. Appendix 3 lists a comprehensive and detailed summary of both current and potential measures identified through the evaluation. This has been consolidated in Table 22, which summarises the key measures that could be used to evaluate hub performance consistently, guided by evaluation participants’ priorities, and with the expert opinion of the evaluation team.

Many sites reported high levels of satisfaction among women who used their services in local measurement exercises, aligning with the accounts of women we interviewed (see Chapter 5 for further detail). There were also accounts of high levels of satisfaction among staff working in WHHs, and possible links to staff retention (as discussed in the workforce findings).

Considerations for measurement and comparison of Women’s Health Hub achievements

Timing: Often hub models were new and emerging, and while local data can provide insights into what has been achieved, participants highlighted that longer-term measurement is required to measure activity, outcomes and impact in a meaningful way.

We need to have a look at that when it’s been running for a much longer time and look at the impact it’s had on the existing [services].

EH1, internal interview

Purpose/vision and local context: Most measures adopted varied according to the aims, model and services offered by the hub, which was informed by local service and population needs, and therefore were not consistent across all models and populations. Some participants with a broad view of WHHs suggested that general health outcomes, for example cardiovascular disease rates or smoking cessation, could be included, though the models we identified focused on reproductive health outcomes and were not addressing these outcomes directly at the current time.

Population/service boundaries, and proportion versus frequency: Currently hub performance is predominantly reported in the form of frequency data, and at hub level, for example referrals received per month, number of LARCs fitted in the hub. While this is a good indicator of activity and processes, it does not illustrate the population-level impact. Hubs may have different footprints/catchment areas, including PCNs and local authority areas. Measuring outcomes at population rather than service level and reporting rates is important to measure health impact and costs in the system and to enable comparison between different areas, populations and models. System-wide rather than organisation-specific performance indicators can also encourage different stakeholders to collaborate to achieve common goals.

Comparing hubs: While there is overlap in some measures used by hubs, these have been locally developed, and there are no shared standard indicators used for reporting. Some measures are consistent, for example referrals, DNAs. The information shared by participants and in documents for this evaluation was insufficient to enable meaningful direct comparison of different hubs and models.

Benchmarking and targets: While some hubs have targets in place, others do not, and it is not clear what an appropriate target would be. Where targets exist, they are not consistent between hubs.

We haven’t done anything formal. Honestly it’s all how many numbers can we get, how many women can we actually get an implant or a coil in, how many can we get covered really. But, yeah, so one of the … managers was actually saying maybe we should have a target each year and I’m like what?! But, yeah, we will.

EH2, internal interview

Comparing sites within a hub: Within some hub models, it may be relevant to compare between sites, for example compare referral rates between GP practices, or compare uptake/activity between different hub locations/clinics or other services offering the same procedures, such as reasons for referral or LARCs fitted at different locations including sexual health clinics. Some hubs are doing this currently.

Trends: For all measures, measuring trend can identify improving/declining uptake and performance. In the evaluation, we identified hubs monitoring trends in different outcomes over time by month, quarter and year, but this would need to be consistent for comparison.

Transfer or increase in activity: For some measures, it may be possible to monitor whether the hub is moving existing activity from primary or secondary care or delivering additional capacity and activity. For example, comparing numbers and rates of LARC fitting in GP practices, in hubs, in SRH and in secondary care gynae. While LARC prescribing in primary care and SRH can be compared using prescribing data, the way in which LARCs are prescribed for use in hubs varies, and this may be more challenging. We did not identify evidence of hubs routinely measuring this, but it will be important to assess value for money and impact on other services in the health system.

Long-term impact measurement: There are many ‘downstream’ impacts of hubs across the life course. For example, there are health, social and economic benefits for women, families and wider society in avoiding unplanned pregnancy, or addressing debilitating menstrual bleeding and pain. We have not identified any evidence of longer-term impact measurement for hub models currently in place.

Measuring costs: Assessing the costs and benefits of WHHs is challenging in such a mixed landscape with different models, in different populations, and with limited availability of data to interrogate economic costs and benefits in a meaningful way. Some hub leaders have reported that their models are cost-effective or cost-saving, but there needs to be further exploration of what this means in this context, given the variety of hub models and services developed. For example, the scope of these existing analyses might be limited to focus on whether the costs associated with WHH service provision are within the limits of the funding available locally, or generate income for the particular GP practice or network. There are potentially a range of cost savings associated with shifting care from secondary care to the community setting. There might also be efficiencies associated with appropriate services being delivered by a multidisciplinary workforce, for example utilising the skills of nursing assistants or advanced nurse practitioners, alongside GPs with special interests. There are also a wide range of benefits that hubs could deliver, through improved health outcomes by providing more ‘joined-up’ care, for example reduced unplanned pregnancy, earlier cancer detection. There are a wide range of scenarios whereby hub models may reduce costs in the health system, but assumptions require further modelling and testing, particularly over the longer term. There is also a range of potential unintended consequences which may impact on any costs, for example, there may be unintended duplication of services within the local healthcare system, particularly in the early stages. A number of potentially ‘hidden’ costs were identified in our evaluation, including the time and skills invested by hub leaders, particularly in setting up the hubs, and in relation to the inefficiencies created by needing to adopt ‘workarounds’ to deal with the challenges associated with fragmented commissioning arrangements.

Unintended consequences: With any complex service intervention, it is important to consider unintended consequences elsewhere in the health system, which can be measured as the approach is scaled up. Our participants highlighted a number of areas where this may occur. For example, there is a risk of widening inequalities if the new hub service is easier to access for already advantaged women (measurement of inequalities is discussed further in the following section). An important concern for some was the risk of deskilling primary care staff or destabilising GP practices due to care moving from primary care to the hub, although many of our participants were keen to stress that models were intended to strengthen and complement primary care. A related worry for some interviewees was that GPs receiving additional training in women’s health may leave general practice to work in hubs or the private sector, depleting an already stretched workforce, with at least one account of this occurring. It is also possible that WHHs will increase costs to the system, and this requires careful evaluation. Increased costs could result from a more expensive model, by unlocking unmet need and increasing volumes of care delivered or by duplicating existing provision in other services.

Challenges in measurement: In addition to the challenges described above, the work of collecting data and measuring activity and outcomes required staff capacity and expertise. In one site, an expert from the pharmaceutical industry provided implementation support which included designing a template for the GP record to enable hub leaders to extract data from systems more easily. Some hubs had specific individuals whose role it was to assemble and report data. Further challenges described included knowing what to collect, difficulty interpreting data, and the fact that primary care does not routinely report women’s health activity in a way that could be easily compared. It was also suggested that some of the more measurable outcomes at system level were downstream, for example prevention of termination of pregnancy, meaning it would be more difficult to demonstrate a causal link with hub activity.

The approach to tackling inequalities

A range of approaches were described by hub leaders to address local inequalities:

• Providing clinics in areas of greatest need/deprivation, for example rural areas.

• Providing materials and outreach for specific communities.

• Mapping inequalities, monitoring uptake of hub services in different groups/areas and planning to address gaps, for example in trained LARC fitters.

• Providing choice of telephone and video consultations to enable women with commitments to attend.

• Providing phone access in addition to online, though some services are only providing digital.

• Working with third-sector organisations, patient engagement events.

• Engagement focused on specific groups.

• Ensuring that clinic locations have adequate transport links.

• Providing out-of-hours access.

• Providing GP education focused on needs of underserved groups.

Participants also suggested strategies not yet in place, including using a mobile WHH bus to visit different areas, self-referral to minimise barriers to booking and colocating the hub with other services used by women, for example children’s health services.

In terms of health inequalities, I suppose by being an open access clinic it means you’re removing the barriers to care of going via the GP who they have also referral who then does it for somebody else and signpost and that can be quite disruptive to ladies, especially busy ladies so I suppose one of the things is direct access because that’s one phone call, one referral form, that would certainly mean that you would contact instead of putting off that and especially because the GP lines are so busy with all the other problems, so I think that would probably decrease your health inequalities.

EH4, internal interview

Potential challenges in tackling inequalities through WHHs were also identified, including the stigma and taboo surrounding women’s health issues for some communities, and awareness and access issues. Overall, out-of-hours provision was rare. Where there were few venues, it was suggested that they may be difficult for some women to reach. Women with more complex lives and fewer resources may be particularly affected, and there were concerns that demand for services was so high that it would be more disadvantaged women who struggled to gain access.

We cannot create the capacity to meet the demand and it is always, when things like that happen, it’s the ones who aren’t articulate or intelligent or – not intelligent, that’s the wrong word, but who lead, some people lead a chaotic lifestyle. Some people have young kids. Some people who aren’t able to, they can’t speak the language, they aren’t able to navigate the system are the ones who get left out and that’s a big, big concern for us. And it isn’t because we are not trying, because we are.

EH4, internal interview

Participants also highlighted the importance of women knowing about the service and that their problems could be addressed:

I mean, people put up with stuff for years and years and you just think if they don’t know about it or it’s not promoted then how are they going to know what the treatment is to get better.

EH4, internal interview

What is measured?

Systematic measurement of the impact on inequalities was still emerging in the sites we explored. Information on outcomes gathered through this evaluation and accounts from local leaders indicate that further work is needed to understand how hubs address inequalities quantitatively. Currently local performance measurement tends to focus on activity. Uptake and impact of hub services for different population groups, for example minorities or socially excluded women, are not routinely assessed. There was one account of comparing demographics of women accessing the hub with the local population and discussing with commissioners and working with communities to address gaps, but more recently funding pressures made this more challenging.

Hub leaders stated that they were committed to addressing inequalities, and it is often a specific aim of the models, and this is reflected in approaches which provide services in underserved or deprived geographical areas, though it is not clear what proportion of women accessing the services are in the target groups (e.g. affluent women may travel to access hub services located in a low-income area).

What could be measured to understand hub impacts on inequalities?

Comparison of general measures of uptake, activity and outcomes by different groups of women, and how this compares with the general local population served, will be key to understanding inequalities impacts and unmet needs. It is likely that patterns of use of different services in the local health system may vary between groups, so measuring access and outcomes for different services in the local health system beyond the hub is important. Measures that could be used to explore inequalities may vary according to local population needs and system priorities, but could include:

• Deprivation (e.g. Index of Multiple Deprivation decile of woman’s postcode)

• Ethnicity

• English-language needs

• Age

• Specific socially excluded groups (e.g. homeless women, asylum-seeking women)

• Diagnosis (e.g. women with specific issues such as endometriosis)

• Disability.

Comparing Women’s Health Hub success in addressing inequalities

Comparing hub models’ achievements in this area will be challenging, due to the variation in local populations, needs and service landscape. Success in access/outcomes for key demographic groups can be compared between hubs, for example measuring LARC access by demographic group. However, it will also be important to understand how hubs are meeting the needs of their specific local population, what the local priorities are and how they have tailored their local provision, to avoid inappropriate comparisons of performance on inequalities. Where hubs have similar models and populations, this will allow for appropriate comparisons and benchmarking. Where hubs have particular priorities internal comparisons of trends may be more appropriate, for example how referral rates to the hub for women from deprived postcode areas change over time. Here a local leader describes the need for local tailoring and for population intelligence.

You can learn from other models, that’s great, but the key thing is very much tailor the needs of your local population and fully understanding what women need locally … there’s so many variations that you just can’t, you know, treat things [the same] because they’re different women, they’re different demographics that you will find that they tend to approach services differently, access services differently.

EH1, internal interview

Women’s Health Hubs’ impact on system-level inequalities

Some participants highlighted the challenges in tackling inequalities where the hub was not accessible to all women in the local area.

I think the big inequalities for that service is that it’s just one part of [name of place] … how do we level up, because we definitely, I wouldn’t want to see anything levelled down, but then how will everyone have, you know, do we – ideally you’d want a hub in every locality wouldn’t you?EH4, external interview

There was a sense among several staff that accessing WHHs could help tackle stigma around women’s health, offer women more choice and meet their needs. Hubs being based in GP practices were seen by a small number of interviewees to help ensure women can access services, due to their familiarity, location in local communities, and a more acceptable environment and reduced stigma, particularly compared with attending a sexual health clinic.

And so I think a general clinic [in a GP practice] with a safe space inside it could be a really good place, because no one’s going to bat an eyelid if someone sees them going there. But if they’re going to a dedicated STI clinic it’s got a big fat label on it.

EH2, internal interview

Accessibility of WHHs was another consideration for several, including parking and public transport requirements, and local venues to facilitate access. In one site particularly, rurality and available travel routes to the hub were considered potential barriers to access.

A few interviewees mentioned provision for those for whom English is not their first language, explaining what interpreting support was in place, though there was a sense that this could be improved.

… we use Language Line and all of that. So that side of things I think probably needs to be better but … because lots of patients have somebody helping them, either a sister, people that don’t speak the language, or a partner or whatever, but then we involve Language Line ….

EG2, internal interview

It was noted that digital access to hub services may lead to the exclusion of some, for example older women, and so offering alternative ways to access and receive services was important.

… people who are lost will be the people who cannot use computers, people who do not use English as their first language.

EH4, internal interview

The potential for hubs to exacerbate health inequalities was flagged in a small number of interviews. Reflections centred on geographical variation in provision across areas with WHHs, resulting in inequalities in access. In one site, funding cuts and reorganisation was reported to have reduced capacity to undertake inequalities-focused quality-improvement work.

And at the moment there is an element of that [postcode lottery] because it’s not up and running in all the PCNs.

EH2, external interview

It was suggested that there were challenges in accessing services via a GP referral model, and that some women would find it harder to get an appointment; therefore the difficulties in accessing primary care at the current time would need to be considered.

A small number of participants suggested that GP referral could equate to easier/universal access, for example removing the need for women to have to find the service themselves. Additional approaches to addressing inequalities were highlighted through the survey, including:

• Engaging with particular ethnic minority communities, for example through engagement events.

• Launching services in areas of particular high needs, for example an area of high social deprivation.

• Services in easy-to-access locations with adequate transportation links.

• Offering evening and weekend appointments.

• Consideration of domestic violence at initial consultations, for example screening questions.

• Use of interpreters.

Awareness of Women’s Health Hubs and services

Most women interviewed who had received care in a hub were not aware of the term ‘Women’s Health Hub’, or that it was the name of the service they had attended. Interviewees referred to the services by different names, for example community gynaecology.

I had no idea these hubs existed. So, just having information out there that they are there would be great. More information about them, the sort of services you can have, and what you can even access.

EH4, patient interview

Some had not known that the service existed or was offered in a particular venue until they were referred or signposted there, or had enquired locally.

If it wasn’t for the nurse at my doctor’s surgery referring me, I wouldn’t know anything about it. Didn’t even know that [venue] … I’ve lived here for about 14 years but didn’t even know that existed.

EH1, patient interview

There was also some lack of awareness regarding who organised hubs and what services they offered. Some described only knowing that the hub offered a service particular to their need. Similarly, in the focus groups many women were unaware that WHHs existed, what or where they were or what they offered.

I think women need to know that these services are there because from this little meeting, it looks like a lot of women are not even aware that the service is there.

EH1, group interview

In one group, a woman shared an example of searching the internet for community gynaecology and menopause support, but their local hub did not appear in the results.

Accessing and receiving care at a hub

Experiences of Women’s Hubs and wider services

Using health services for women’s health needs

During focus groups, women who had not used hubs reflected on the services they currently used for support with women’s health-related issues. Women often described going to their GP first, though they reported challenges in accessing the GP, with some expressing preferences for female doctors, who were not always available.

I would love for it to be a woman, you know? So all those things they have to take into consideration. That’s why cultural issues. That is not something that we do in our culture so for certain things like that it has to be a woman.

EH1, group interview

Some mentioned that there wasn’t much support available for their women’s health needs, that it had reduced compared with times past, with one woman describing it as ‘non-existent’.

It must be about 10 years ago they shut them [community contraception clinics] down because then you had to start going to the doctor’s, but then you’re taking an appointment off someone to get your pill.

EH2, group interview

Consequently, a few women had sought alternative methods of support, including accessing community groups or paying for alternative therapies or private health care. For information around women’s health issues, women primarily described either talking to their friends or accessing information online. However, this was not possible for all, for example some who did not use the internet described relying on family or friends to help.

Two groups, including one in a more deprived community, also raised concerns around ‘postcode lotteries’ and whether hub services might not be accessible for all women. Some questioned whether women in more affluent areas might find it easier to access help.

When they are open I am at work, so I think if this hub here it can also be in [name of place] – it’s supposed to be everywhere, not only in [name of place].

EH1, group interview

A need for women to self-advocate to access/navigate services and receive support was also raised by another group in a more rural community, who suggested that accessing provision relied on women speaking up for themselves. Some described how women from certain communities may have needs that were not being met; two groups of women from ethnic minority backgrounds expressed preferences for describing symptoms in their first language and being able to speak with someone who understands them. One group also mentioned the importance of being able to have written information translated to aid understanding, while in another some mentioned wanting to see a healthcare professional who understands their culture or background. Both groups also expressed preferences for seeing female doctors.

… people who can speak the languages so they can express themselves because what we’re finding is when you’ve got an illness, when you try to translate it into English, first of all it’s explaining yourself, then secondly you might not get it correct in English and the other person can’t understand so they don’t put down the severity of the illness

EH4, group interview

Yeah, to understand the women – culture, background and their language because some people will speak English as their second language. Sometimes we can’t express what is going on, you know, because we can’t say it in English.

EH1, group interview

What do women think Women’s Health Hubs should look like?

Participants were invited to reflect on what they would like women’s health services/hubs to look like. They gave examples of services they would like to see, including contraception, cervical smears, fertility, breast care, screening, maternity and postnatal services and support, sexual health and menopause care. Mental health support was also sometimes mentioned. Hubs could offer education, advice and information for women in local areas, and several expressed a desire to be able to see female doctors in hubs. While many focused specifically on women’s health services, a few stated that they would like a hub to be somewhere where women could receive advice and checks for any health problem, for example blood pressure. There were suggestions that WHHs could include support groups or be a ’safe space’ offering women a private, trusted place to go, for example for women who had experienced abuse.

I would like to see consultation, advice, like people come to you to ask say about like contraception or sex or any health problems really that they’ve been thinking about. And also somewhere where someone is a victim of domestic violence or sexual abuse or anything like that, that they could come and it would be a safe space.

EH4, patient interview

Several participants described how WHHs could be somewhere you could get everything you need in one place, without referral elsewhere, offering support holistically across the life course. When discussed, interviewees and focus-group participants described the idea of WHHs in positive terms, saying that they could be good for women:

I do think it’s a great idea to bring everything together because there can be so many anxieties about accessing support …, to know that you’re going to a space that has really good knowledge and is confident in offering support to women who menstruate I think would be really valuable.

EH4, patient interview

However, there were a small number of concerns raised about the sustainability of any new services:

… the hub to be there, to continue, because maybe it could reach up to 2 or 3 years and then close down, you know? So it’s to leave it, to continue this service to grow, not to be closed down.

EH1, group interview

In two focus groups, women suggested WHHs could be mobile, with clinic facilities in buses that can go to where they are needed in local communities, for example a local supermarket car park or mosque.

… there should be a mobile unit that has everything to do with health on it that goes and stands in different car parks across [place], like a mobile that can be moved, and people can go in and have a screening done, have everything done ….

EH4, group interview

The importance of accessibility, and the potential for services being more community-based, was also emphasised:

… accessibility is important. The hub has to be near the people so they can reach it with transport. And also access for those women who have disabilities. So there has to be more accessibility and also the time, like what I said before, is also important. So the location of it is also important, it has to be local. Also the transport is accessible.

EH1, group interview

Further, as mentioned previously, the opportunity to access support in a woman’s first language would be welcomed.

Facilitators and barriers to women’s uptake of services

Across sites, facilitators and barriers could be identified or inferred from interviews with women and staff, and in focus groups. Factors included an awareness of hub services, a convenient or familiar location and stigma associated with accessing sexual and reproductive health services (Box 19).

Staff views of women’s experiences

Professionals working in and outside the WHHs were positive about patients’ experiences. They mentioned a range of benefits, including easy and convenient access, a more intimate or relaxing experience, and opportunities for some continuity of care. Some reported that women were more able to ask questions, were more informed and empowered, listened to, and able to take their time in appointments.

… we have more time, more used to dealing with people and so communicating with patients and that’s really appreciated, so people are very thankful for the time and thought that goes into their care, they feel heard and that their problem is addressed and they understand how to manage it ….

EH3, internal interview

There were also comparisons made to care provided elsewhere in the system: for example, the value of shorter wait times compared to other services and a sense that a hub could offer a more comfortable experience.

… the wait time for [place] at the minute … it’s brilliant compared to what they would have been expecting, which is a three month wait to go to [different place]. So at the minute, very well received.

EH1, internal interview

In one site, several professionals highlighted the value of patients being able to directly re-contact the service following treatment completion, should they experience any issues or need further help, providing reassurance for women. One interviewee described how this differed from other services, such as in secondary care, where a patient would be discharged and require a new referral to access further support.

Across all exemplar sites, receiving positive patient feedback was mentioned by professionals. In one site, interviewees remarked how women liked the hub so much they wanted to remain a hub patient, while in another staff talked about receiving few complaints, which they stated reflected their service quality.

I do feel that what, the care that they’re actually receiving is just so humungous to them and life changing, they’re telling their friends and we do get a lot of that.

EH3, internal interview

Definitions, aims and models

• Women’s Health Hub models across the UK were diverse, with different perspectives regarding the role and definition of a ‘hub’, and varied service offers, catchment areas and nomenclature. It was rare for hubs to offer and advertise multiple services at the same time, and the terms one-stop shop and hub-and-spoke were applied differently. Most hubs were evolving with plans to expand their offer and/or reach. The majority of hubs were multivenue, and there was a mix of GP and community clinic venues, with most GP-based.

• Some participants reported that there was a shared vision across stakeholders about what a WHH is and should achieve, and WHHs broadly aimed to improve local women’s health access, quality and experience. The hubs we identified inhabited an ‘intermediate space’ between standard primary care and specialist secondary care. The boundaries varied in different hub sites.

• Some professionals and women wanted to see a wider range of services impacting on women’s health, for example maternity, cardiovascular, mental health, though the focus of hub implementation was on reproductive health and gynaecology services.

• All hubs used a GP referral pathway, and while some expressed a desire for self-referral, concerns were raised regarding the ability to manage demand without a primary care referral model.

• Hubs were clinically led by doctors, usually GPs with special interest. There was a mix of formal and informal leadership and oversight. There were a range of perspectives about leadership, and it was not possible to determine an optimum leadership model from the available data. There was no common approach to staffing, and while GPs were usually key, there were examples of diverse multidisciplinary delivery models, and there were different opinions on the clinical benefits and costs associated with delivery by different health professionals.

• Commissioning models were diverse, and there were many examples of formal and informal creative approaches to identify and access resources to set up and run WHHs and, in some cases, share costs across different parts of the health and social care system. No clear optimum commissioning model was identified as it was dependent on local context and interest, and existing systems/processes.

• Many WHHs supported women’s health training, education and capacity-building in health systems, although the scale and scope of these activities varied.

• We found no evidence of WHHs integrating with other hub models currently, for example community diagnostic hubs, perinatal mental health hubs, though these models are also still emerging.

Service aims and outcomes

• Most parts of the UK did not have a WHH. We identified 17 active hubs, and 5 areas setting up a service. There were also many other services providing women’s health care in the community which did not meet our definition of a WHH.

• Hubs across the UK have provided care for many hundreds of women. Measurement of processes and outcomes was evolving, and outcomes measured and data sources varied, making comprehensive assessment and comparison difficult.

• In part due to hubs often being in their infancy and some only recently starting to see women, data on outcomes were limited, but where they were reported by WHHs they indicated that WHHs have the potential to deliver shorter waiting times, increased LARC fitting rates, and reductions in secondary care gynaecology referral rates and waiting lists.

• Some participants expressed concerns about potential unintended consequences of WHHs such as widening inequalities (if women in already more advantaged groups find it easier to access hub services), destabilising existing services and workforce, or increasing costs (either through service duplication or unlocking of unmet need).

• While hub leaders aimed for models to reduce disparities, and were implementing strategies to do so, evidence was still emerging regarding whether this is achieved in practice. Data limitations meant that the impact of WHHs on inequalities could not be assessed.

• Women reported a positive experience of hub access and care. Generally, women using hubs and women in the community were not aware of the term ‘women’s health hub’ but welcomed the concept. Our Women’s Group suggested that the ‘hub’ term may be confusing as it indicated that hubs were a place.

Implementation facilitators and barriers

• Interviewees described successes in hub implementation, suggesting ‘good practice’ and providing learning for others developing hub models.

• Committed, collaborative clinical and non-clinical leaders working across boundaries, with sufficient workforce capacity and enthusiasm, appear to be important to success. Hubs were often implemented incrementally, with piloting, evaluation and evolution of models, and relied on leaders devoting time, resources and goodwill ‘beyond the day job’.

• Additional expertise to support implementation was key for some hubs, for example NHS, local authority, pharmaceutical company provision of strategic/clinical/project management capacity. Leaders described using local intelligence to measure and model population need and to estimate hub costs and benefits to inform implementation.

• There were examples of established hubs sharing policies, advice and tools to support colleagues implementing new hubs elsewhere without ‘reinventing the wheel’.

• While ICBs were viewed as a potential route to expedite hub scale-up, participants noted that there were no designated system leaders with responsibility for women’s health, and this area was competing for attention with acute health and social care priorities.

• While some hubs had involved women in service development, this was not extensive.

• Participants highlighted the need for flexibility in hub models to meet the local context, balanced with some standardisation to understand and compare hubs and outcomes across the NHS.

• A number of the challenges described are common to health and service improvement work, including access to funding, facilities and equipment, workforce, stakeholder engagement, and wider system competing priorities and pressures, further exacerbated by COVID-19. 66,67,70,71,110

• Many of the challenges were familiar in integrated care. Commissioning and funding barriers were often cited, along with workforce challenges, lack of interoperability of IT systems and data-sharing, identifying physical space, ensuring smooth patient pathways, and allaying concerns about loss of activity and funding in other parts of the system. There were examples of overcoming these barriers to achieve different forms of integration.

• While hubs had frequently adopted creative approaches to identifying funding and overcoming commissioning barriers, often they constituted ‘workarounds’ rather than long-term solutions. Some hubs had reached an impasse in expanding their offer due to commissioning barriers, for example identifying what funding and activity could move from secondary care gynaecology to the hub, or identifying a long-term solution to enable offer of LARC for both gynaecological and contraceptive reasons in the hub. Finding solutions to the challenge of transferring money or resources between organisations has been identified as critical in the success of integrated care models. 70,73

• We found evidence that in some models information-sharing, IT and interoperability issues had impacted on WHH referral, prescribing, testing, follow-up, record-keeping and communication across care interfaces, which are challenges facing many working to integrate care. 111 Strategic-level action is already under way in ICSs to address these challenges, and the barriers are not unique to WHHs. However, WHHs are often at the ’sharp end’ of cross-boundary working.

Implementing at pace and scale nationally

• Hubs were small scale and rare, and the evidence of effective approaches to implementation was emerging. Further scale-up of WHHs is likely to take time and resources, and different health systems will be at different stages of readiness. Sustainable national scale-up and spread are likely to require an incremental approach, and resource to support implementation and share learning, with concurrent, consistent monitoring and evaluation.

• Diversity and local autonomy to develop context-specific solutions need to be balanced with a degree of standardisation. While services vary between hubs, it may be beneficial to develop a ‘core’ offer that all WHHs should aim to provide. This should be developed through collaborative, multidisciplinary prioritisation, which includes women with different experiences and backgrounds.

• A collaboratively agreed national set of definitions for key terms would support clear communication among stakeholders, including ‘Women’s Health Hub’, one-stop shop, ‘holistic’ and ‘hub-and-spoke’. Defining the types and levels of integration being adopted beyond these labels would facilitate clear understanding and comparison of models. A clear definition of criteria to be met for a WHH to be considered ’set up’ rather than ‘in development’ would support monitoring of implementation across the NHS.

• Many areas lack the local champions and contexts that support WHH establishment. Implementation may be expedited by introducing designated roles at regional and ICS level to raise the profile of women’s health.

• There is a substantial community of practice and expertise in women’s health driving the hubs agenda forward, including national organisations and leaders from across disciplines and geographical areas. Continued national engagement and support for these groups can aid expansion of this community and share learning. While the focus of the Women’s Health Strategy and most of our evaluation was England, there is further learning to be gained from other areas, particularly Northern Ireland, where WHHs have been established to serve the whole population.

• The commissioning challenges in English women’s health care are a major barrier to providing a comprehensive WHH offer. Existing WHHs had developed a range of creative ‘workarounds’ to overcome barriers, but these generally were not long-term solutions, and the underlying challenges remained. Local partners need to develop joined-up, co-ordinated and collaborative commissioning approaches for WHHs, focused on achieving better outcomes for women, reducing inequalities and ensuring the efficient use of resources across the health and care system. ICBs, with their responsibilities to plan and deliver joined-up services focused on population need, would seem well placed to play a role in such developments. Since the evaluation, Women’s Health Champions have been appointed in each ICB to drive this agenda. 120 There may be scope for national-level guidance to further support local commissioning approaches around WHHs (acknowledging the need to account for local contexts), drawing on the existing evidence and evolving processes.

• Ongoing WHH implementation can draw on the extensive evidence base regarding ‘what works’ in implementing integrated care and hub-based models.

Embedding Women’s Health Hubs in local health systems

• Leadership was key in establishing WHHs at the local level, and identifying, resourcing and supporting designated leaders will be crucial to establishing hubs in new locations. While hubs were all led by doctors, other members of the MDT also made a substantial contribution, and there may be opportunity to develop nursing and other professional leadership roles as hubs evolve.

• Context-specific, system-level assessment of needs, resources (particularly workforce), opportunities and priorities involving women and other local stakeholders will be necessary to identify gaps, opportunities, and what is possible, including avoiding duplicating existing provision that is working well. WHHs can play an important part in a local women’s health landscape, aligning with other initiatives and services, such as access to contraception through community pharmacies.

• Our evaluation focuses on areas where WHHs had been successfully implemented. Some areas may face significant barriers to WHH establishment, which require further exploration and support. It is possible that on assessment some areas may deem that a WHH is not the best approach to improve women’s health in their population at the current time.

• Clarity regarding where hubs sit in local pathways is crucial, and their focus and specialist input are likely to vary based on local needs, assets and challenges. For example, a hub model may deliver one or more of the following: (1) elements of what is ’standard’ GP care because it has not been possible to deliver locally (e.g. menopause care), or (2) a more specialist level of input already provided by some GPs (e.g. LARC fitting) to address local access issues, or (3) services that are traditionally available in secondary care (e.g. hysteroscopy, ultrasound) to reduce the need for secondary care, tackle waiting lists and bring care closer to home.

• For WHHs to be sustainable in the longer term, local partners will need to work together to develop integrated commissioning and delivery of hub models, clearly identifying the types and levels of integration being adopted, and with ICBs playing a key role in overcoming current barriers. As outlined above, this will depend on a detailed understanding of local needs and systems, and effective partnership working to identifying optimal approaches for addressing local challenges. To avoid confusion and ensure safe care, joined-up pathways and feedback loops are needed across care interfaces, including test results, follow-up planning and information-sharing. Work to address challenges and establish ways of working in the wider system can facilitate integration, including electronic record interoperability and information transfer, prescribing and ordering tests between services.

• Hub design and implementation approaches need to explicitly identify and measure the forms of inequality being addressed, and consider intersectionality between multiple dimensions of inequality. Leaders may wish to consider focusing hub implementation in or for specific underserved communities to tackle inequalities head on.

• It will be important to identify and mitigate potential unintended consequences of hub implementation, for example duplication of existing services, widening inequalities if less disadvantaged women find it easier to access services, and detrimental impacts on other services.

• Many hubs aspired to deliver a wider range of services than they were able to offer, with LARCs a common focus. Participants also highlighted other areas which they would like to see more integrated, for example maternity services. While leaders have worked tirelessly to develop and implement hub models, their work was often focused on specific aspects of women’s health rather than encompassing the whole life course. There may be benefit and learning to be gained by closer collaboration and identification of interdependencies with colleagues and service users working on other community integration and hub models, for example family hubs, sexual-assault referral centres, integrated community dermatology.

Ensuring a woman-centred approach

• While women were involved in the development of some WHH models, there is scope for much more national and local involvement of women with a range of lived experiences to ensure that approaches align with their needs and priorities across the life course, including consideration of women’s wider needs beyond their reproductive health. Involvement of women whose health needs have historically been underserved is particularly important.

• It is essential that women know how to access the care they need if the service landscape becomes more complex. A ‘hub’ could mean a venue or a place, but where it incorporates multiple venues and virtual support it may be a challenging concept for the public to understand. We heard mixed views regarding whether it is important that women know that they are accessing a WHH, and whether WHHs should be a recognisable entity in the local health system, and this would benefit from further exploration with professionals and women with diverse backgrounds and experiences.

• It is also important that women are able to access care, and the GP is often the first port of call to navigate the health system. Many women describe challenges in accessing primary care at the current time, which may be a barrier to WHH access. If alternative referral routes are introduced, it will be important to ensure that they are understood and accessible to all women.

Recommendations for further research

• While the evaluation offered some insights into the potential impact of WHHs, the diversity of hub models, the relatively small number of active hubs and limitations in available data mean that we do not yet have clear and definitive evidence that they will improve outcomes and address inequalities across health systems if implemented at scale.

• There is a need to build the evidence base, with consistent and comparable approaches to description and measurement. Given the heterogeneity in hub models, detailed descriptions of the leadership, commissioning, contracting, provider and delivery models will be essential to understand and compare approaches, including describing the levels and types of integration.

• Future evaluation would need to consider both hub-level and system-level impact and costs across services and the population and explore potential unintended consequences of WHHs. Many hubs are in their infancy, and many more will be implemented in the near future. Further evaluation should only be undertaken once models have become sufficiently operational and data are available to enable measurement of impact.

• To understand the impact on inequalities, future work should apply an intersectional lens to take account of the complex barriers faced by different women, and compare the perspectives, experiences, access and outcomes for different groups of women living in areas served by hubs across the life course. Along with impact evaluation, there is also a need for further work to understand implementation, the resources required, optimum approaches and why WHHs have been difficult to implement in some areas.

• There are some exciting innovations being delivered via WHHs which could be explored through further work, such as virtual group consultations.

• There are some key assumptions which would benefit from additional exploration, including: what kind of care women want and prefer; the relative benefits of different women’s health service models (including services not meeting our definition of a WHH), clinical leadership approaches (including the role of nurses and allied health professionals), different hub sizes/footprints and workforce models; the cost-effectiveness of different hub models and comparison with other types of service provision; the impact on workforce challenges and retention; and whether hub models can provide a genuine one-stop shop.

Box 21 provides a summary of key messages from the evaluation.

Defining Women’s Health Hubs

At the time the evaluation was undertaken, stakeholders highlighted that the ‘Women’s Health Hub’ (WHH) label did not have a clear and consistent definition, and not all organisations providing women’s health services in the community would refer to themselves as WHHs. WHHs are not necessarily a ‘place’ but a ‘concept’ and are distinct from other hubs which may support women’s health, for example mental health and family hubs, though inevitably there are links. We have explored the diversity in terminology in use, and perspectives regarding nomenclature, as part of our evaluation.

Using the term ‘women’

While we refer to women throughout this document, we recognise that WHHs may also serve people who are transgender, non-binary, with variations in sex characteristics (VSC) or who are intersex. The evaluation considered the needs of all people who are in need of services provided by hubs and was not limited to cisgender women. We have reported on issues of inclusivity around gender that were found in our data.