Published: 10/03/2005, Volume II5, No. 5946 Page 30 31 32
The drive to see sexual health services delivered by multidisciplinary teams has not been smooth. Rebecca Coombes finds out where the plan has worked and why
Marian Everett is a rare breed in the field of sexual health. A consultant in sexual and reproductive health, she is also trained to deliver genito-urinary medicine services.
The fact that she is dual-trained has allowed West Hull primary care trust to open a clinic that offers services previously only available in an overcrowded GUM clinic. Formerly a traditional family planning clinic, Goole sexual health clinic now offers testing, partner contact tracking, treatment, a telephone results line and a full range of contraception services.
'It has immeasurable benefits because we are focused on all aspects of sexual health. You can have a sexual health screen and get some contraceptive pills at the same time, ' says Dr Everett, who is supported by a male GUM nurse and family planning nurses.
The service also echoes the vision laid out in the public health white paper, that 'services will be delivered by multidisciplinary teams in a range of settings'. It is important, said the paper, that clinicians in GUM settings are used appropriately rather than on more routine consultations.
But if the vision is clear, the route to delivery is less so for many services around the country.
Even in Dr Everett's patch, where there is a clear commitment to devolve routine sexual health work to primary care, there has been a struggle to organise the re-training of health professionals to deliver new services.
West Hull PCT head of community modernisation Martin Dougan explains: 'A high percentage of the population are at risk of sexually transmitted infections, but at the moment specialists are involved in all tiers of sexual health and that is clogging up the system.' He says primary care can deal with all but the most complex needs of patients. Chlamydia treatment, for example, is fairly standard and can be delivered by patient group directives - without a GP, but by a nurse or pharmacist.
The problem is how to achieve that transition, he says. 'There is a lack of skill and knowledge across treatment systems, especially in primary care. For example, contact tracking is required if you are going to carry out screening and testing. You have to have a way of contacting partners. We currently do not have those skills in primary care.
'But to train and improve the workforce you need the bodies to do it. We need to release people to go on further training to provide more advanced and accessible services but also the need to keep these services running while they are away.' There is no doubt that PCTs are under pressure to deliver as never before. Last year's public health white paper Choosing Health introduced sexual health into PCT local delivery plans for the first time. Last month public health minister Melanie Johnson, giving evidence to the Commons health select committee, said PCTs will be 'rigorously inspected' against outcomes.
The National Strategy for Sexual Health and HIV had already mapped out goals in 2001, including reducing rates of teenage pregnancies by 50 per cent by 2010.
There has also been non-ringfenced funding to support this. In November 2004,£300m was pledged to 'modernise and transform' sexual health services in England, more than half of which is to go towards modernisation of GUM clinics.
But despite the pressure, observers are rather gloomy about any progress. Health select committee chair David Hinchliffe remarked: 'This is not an issue that MPs get constituents writing to them about. As politicians we are not under pressure to do something on this.' A PCT sexual health manager, talking to HSJ anonymously, adds that neither are many PCTs. 'If you do not make meeting these targets a hanging offence they may as well not exist.' Recent figures from the Health Protection Agency suggest that one white paper target for 2008, that everyone referred to GUM services should wait no more than 48 hours, could be difficult to achieve. The HPA figures show that currently only-one third of patients are being seen by GUM within 48 hours.
Mr Hinchliffe told Ms Johnson that on a recent visit to Yorkshire he had heard of one clinic that did 'guarantee' an appointment within 48 hours. 'However, this is achieved by not answering the telephone once all the following two days' appointments are full, ' he said.
On the issue of white paper targets, a Department of Health spokesperson says PCTs should already have conducted a local needs assessment, and should be considering developing managed-service networks, and looking at the local workforce implications and training needs. The DoH will also be setting out further information in the details for implementing the white paper.
But West Midlands South strategic health authority programme lead for sexual health Paul Sanderson says: 'SHAs are bogged down in LDP submissions and it is clear there has not been enough improvement. Epidemiology with gonorrhoea seems to be moving the other way. It is very early days - at the moment it looks like they are going to be hard to meet.
'PCTs have been given two extra targets they knew were coming. At the same time, by tying them to Choosing Health there should be enough resources and a high enough local priority to make it happen.' One sexual health manager at PCT level, who did not want to be identified, says his authority was 'not even close to reaching the 2008 target'.
He continues: 'The issues are around capacity and resources. It is just so political. There are huge overspends in some PCTs so they can't invest in any innovative service designs.' This is a pity, he says, because investing in service redesign could reduce costs long-term.
'You can treat chlamydia with a£10 antibiotic in primary care and perhaps save the NHS thousands of pounds in infertility treatment later on.'
THE STOCKWELL PRACTICE
DR STEPHANIE MAY
The Stockwell Practice in south London has been a personal medical services practice with a special interest in sexual health for the past three years.
It offers a level-2 sexual health service, including tests for sexually transmitted infections, partner notification, HIV counselling and testing and a full range of contraceptive services including implant fittings.
Taking the initiative Dr Stephanie May (pictured above) says: 'It has taken a big educational initiative to achieve this. The GPs and practice nurses went on a training programme and did clinical placements. A genito-urinary physician came to the practice one day a week for six months, saw patients, told us what to do with individual cases, set up systems and protocols for HIV tests. She got us really thinking about sexual health.' She says modernisation of testing techniques means more patients can be treated in primary care, but adds that a key factor is a new willingness on behalf of GPs and GUM clinics to redesign services.
There is resistance from GUM clinics that have traditionally been the sole provider of sexual health services, although GPs have been providing services for years.
'It is important we maintain a choice of provider in sexual health services. A good proportion of our patients have been to a GUM clinic and had a long wait. They would prefer to come here.
'But given the rising number of STIs I do not see the situation improving unless sexual health services are mainstreamed as part of GP services.
'Clinics can't cope with rising demand, and a lot of the care is basic medicine. They should be focusing on cases at the other end of the spectrum.' Dr May appeals for more joint training and common prescribing protocols to make the shift from acute hospitalled sexual care to primary care-level.
'The relationship between GU departments and local GPs is moving.
Not before time but there is more dialogue.'
MODERNISATION GUY'S AND ST THOMAS' CHARITY
The sexual health modernisation programme has the relative luxury of being funded by a charity.
The Guy's and St.Thomas' Charity is currently funding two years of development work towards modernising sexual health services for Guy's and St Thomas' foundation trust, King's College Hospital trust, and Southwark and Lambeth primary care trusts.
The resultant proposal will then be given up to£5m of pump-priming funding to get established.
Justifying the cause
Programme leader Vikki Pearce says a key factor has been the feasibility study carried out across all GUM clinics, sexual health and reproductive clinics, GP practices and community pharmacies.
The study also canvassed the opinion of users. It found that around 9,000 patients a week present at a sexual health service across Lambeth and Southwark.
Ms Pearce says results for the GP practice and community pharmacies were especially interesting.
'We always knew that GPs provided the bulk of contraception, but we found that sexual health activity in our sample accounted for 16-19 per cent of a practice's workload. If you scale up the data, that is the same number of people attending a GUM clinic.
It tells a powerful story that people do go to their GP when they have a sexually transmitted infection or need a check-up.' She adds that by far the biggest providers of sexual health services in Lambeth and Southwark were community pharmacies.
'People were not just buying contraception, but asking questions about STIs, emergency contraception, testing, and treatment available over the counter.' What was clear was the need to all work together as a 'system'.
'It is not about saying let's get rid of GUM if we bump up the community pharmacists' role. This information is crucial to understand what is going on in your system before you test out any bright ideas.'
Find out more
Focus on Prevention: HIV and other sexually transmitted infections in the UK in 2003. November 2004.
Up-to-date statistics on HIV/STI diagnosis from the Health Protection Agency www. hpa. org. uk
The DoH has commissioned MedFASH to produce recommended standards and networks for sexual health services, due out this spring www. medfash. org. uk
West Hull PCT has set up a joint sexual health and GUM clinic, echoing the inter-disciplinary principles outlined in the public health white paper.
Other PCTs have found blurred skill boundaries and train ing problems to be huge bar r iers to the pol icy.
Some trusts are 'not even close' to meeting the DoH's 48-hour GUM access target by the 2008 deadline.