Stuart Shepherd visits Nottingham to see how the NHS is coping with a surge in sexually transmitted infections, amid calls to keep them top priority
Economic downturn, the threat of global terrorism and climate concerns aside, there is evidence that the UK is having rather too much of a good thing. Over 113,000 diagnoses of chlamydia and more than 7,700 new cases of HIV being reported in 2006 and the dubious honour of having the highest rate of teenage pregnancies in Europe add weight to the theory.
Rising rates of infection are nothing new. From 1996-2002 annual numbers of sexually transmitted infections diagnosed in genitourinary medicine clinics in England rose by 43 per cent. Clinic workloads for the same period went up by 79 per cent and from 1997-2002 the number of HIV cases diagnosed in the UK doubled.
Meanwhile, the first national strategy for sexual health and HIV was published in 2001. This counted modernising services, lowering transmission rates and reducing undiagnosed HIV and sexual infections among its good intentions. A 27-point action plan followed in 2002. At the time, sexual health charity the Terrence Higgins Trust estimated the annual cost of treating infections at something in excess of£1bn. Lifetime socio-economic costs of HIV for the UK were also thought to be rising by anything up to£3bn a year.
In 2003 the levels of HIV and sexually transmitted infections were still on the increase, with GUM clinics struggling under severe strain. A Commons health select committee report in June 2003 described growing pressures on services, a doubling in waiting times for appointments - up to 14 days for women - from 2001-02 and a shortfall in the sector of more than 170 consultants. It was a situation that the then committee chair, Labour MP David Hinchcliffe, called "a shambles".
With the publication of the Choosing Health white paper in 2004, sexual health became a public health priority. The white paper pledged an extra£300m to reduce sexually transmitted infections and make it a matter for local delivery plans. As part of the national strategy, an assessment of all GUM services, with reports highlighting opportunities for improvement and modernisation, got under way in the same year and ran until 2007.
More recently, the NHS operating framework for 2006-07 included six specific service priorities. One was to offer to see people who contacted a GUM service within 48 hours. A target of seeing 100 per cent of patients within this 48-hour time limit was set, to be achieved by March 2008.
By August 2006, however, the Independent Advisory Group on Sexual Health and HIV, created to advise government on sexual health strategy implementation, reported that only 30 of 191 primary care trusts surveyed were spending the Choosing Health money on fighting sexual infections. The others were using some or all of the money to pay off debts instead.
The operating framework for 2007-08 noted improvements in access to sexual health services but stressed the need for more co-ordinated effort to meet the 48-hour target. In October 2007 a letter to all NHS chief executives from the British Association for Sexual Health and HIV (BASHH) and the Department of Health reiterated the progress made. It also pointed out that, although data showed 86 per cent of patients were getting the 48-hour offer and 77 per cent were being seen within 48 hours, there was still much to be done.
Clearly some clinics are getting there, however. "In March 2008 we achieved the 100 per cent offer on 48 hours," says Sally Forster, assistant general manager of GUM services at Nottingham University Hospitals trust. "There are two issues with the target. One is about having the capacity, which this month we have had. The other is the monitoring reports. There are coding issues which mean they suggest we didn't achieve the target, when we have."
Faced with fluctuating and unpredictable demand, capacity, as with just about every other GUM clinic, is a central issue in Nottingham's bid to meet the 48-hour appointment target. Factors such as term-times for students from the city's two universities have to be considered, as does the annual Goose Fair, held over four days in October, when post-revelry visits for a check-up add to the numbers.
"We can go through weeks when demand is flat and others when it is very high," says consultant physician and head of service Chris Bignell. "Media campaigns can influence those levels and bring in a lot of people worried about one condition or another."
Nottingham has been taking steps to increase its GUM capacity for several years in a bid to respond promptly to the 20,000 or so new attendances for which it caters each year, as well as providing ongoing care for around 600 patients with HIV. "The consultants have been proactive and got involved in drawing up protocols and in training nurses to take on nurse practitioner roles," says GUM matron and assistant clinical lead Ali Cargill.
"We knew the 48-hour target was coming for some time ahead and anticipated the kind of skill mix and team building it would take. Since 2002 senior nurses have been taking booked appointment lists of new patients. In complex cases they will refer people on to medical colleagues, but in the future I would very much like to develop combined health adviser/nurse-led HIV services."
Efficiency strides have also been made in follow-ups. Of the 19,300 patients seen in 2006-07, little more than 5,000 were seen at further appointments. "We try and complete the episode in one go and only tend to see people again if their treatment hasn't worked out. I think we have the lowest follow-up rate of any similarly sized GUM department. New attendances also generate more income than a follow-up and it saves on investment in further capacity," says Dr Bignell.
The Nottingham GUM clinic is open five days a week, including two evenings. It offers a mix of appointment and walk-in sessions for new patients, nurse treatment sessions for vaccinations and treatments, an outpatient service in sexual dysfunction, health visitor-led same-day HIV testing and HIV management clinics.
Since November 2006, significant additional capacity has been delivered through services in primary care settings, funded specifically by Nottingham City PCT in response to the 48-hour target. Numbers fluctuate, but on average these services deal with around 170 patients a month.
"Nurses from the GUM clinic, some of whom are prescribers, are leading sessions from the NHS walk-in centre, the GP emergency out-of-hours service and a number of facilities across the community," says Ms Cargill. "Appointments for these sessions are booked centrally through our reception team."
One area where the service still hopes to make further marked improvements will be familiar to other providers.
"We would like all people who come in for a test to know their results, but currently we don't have the resources to contact anyone other than those with positive results," says acting nurse manager and health adviser Kim Mian. "So we ask them to wait for up to 10 days and if they haven't heard from us, then it's 'no news is good news'."
The whole team wants to see this issue resolved. Because of the sheer size of the task, however - on a standard two-session day the clinic generates more than 400 test results - it is still waiting for a technological solution.
For 2008-09, the 48-hour access target drops out of the operating framework priorities list. But it still figures on a list of "previous commitments" that regulator the Healthcare Commission will continue to monitor under its performance assessment criteria.
Meanwhile, the apparent slide of sexual health and HIV down the NHS pecking order has caused concern. The report Sexual Health and HIV: Measures for success in England, put together by an alliance of campaign groups, recognises achievements in reducing rates of gonorrhoea transmission and the significant fall in waiting times, but looks for the reinstatement of sexual health as a priority.
The groups point to the continued increase in diagnoses of many sexually transmitted infections, including HIV, which the report describes as the fastest growing health condition in England. Among a raft of suggested goals is a call for the 48-hour access target to be widened to include all community sexual health services.
"As well as a reduction in the number of STI and HIV diagnoses, we hope for a significant shift of work away from GUM clinics and into community settings closer to where people live," says Paul Ward, deputy chief executive of the Terrence Higgins Trust, one of the groups behind the report.
Networks of support
Chief executive of the National Aids Trust and Measures for Success co-author Deborah Jack sees the move to more multi-disciplinary involvement in sexual health and HIV services as a positive development. "There do need to be proper hub and spoke networks to support this, however, so that there are always good links in place for advice and onward referral with more complex cases. This is not wildly expensive but requires resources, and a worry is that this is not necessarily prioritised."
Another issue that Measures for Success raises is stronger commissioning, explored thoroughly in the Independent Advisory Group annual report for 2006-07. The report acknowledges that the 48-hour target has helped to focus STI care. But it calls for named sexual health champions at PCT board level plus support from finance directors and senior clinicians to ensure commissioners understand the complexities and issues at stake. It warns weak and decentralised commissioning may lead to a postcode lottery of services.
"We would certainly want to ensure that services are commissioned as part of a network with clear governance arrangements that ensures a plurality of GUM clinics and community sexual health, walk-in and appointment services, working together, not against each other," says chair of the BASHH media committee Dr Mark Pakianathan.
Hong Tan, IAG member and director of a pan-London sexual health programme hosted by Kensington and Chelsea council, says: "There are some excellent commissioners in primary care. Increasingly, though, we have noticed commissioning capacity has been reduced. Besides, local commissioning can only do so much and as sexual health is not defined within the boundaries of a PCT or council, there needs to be appropriate regional and national strategic planning and commissioning."
The response in the capital has been to recognise the need for a London sexual health commissioning board that supports equity of access, better value and strategic public health issues.
A place where blushing patients keep their heads down
You would be forgiven for thinking the floor is covered with must-read material. How else to understand the bowed heads of service users in public areas at Nottingham University Hospitals trust's GUM clinic?
The truth is that, despite the 2001 national strategy and sincere efforts by the staff team to normalise the City Hospital-based service, the stigma attached to getting tested for an STI remains. The fear of being "spotted" at the clinic plays heavily on the mind, and patients put a lot of effort into avoiding eye contact. Many clients choose to travel rather than risk being identified at their local clinic. The Nottingham clinic even has patients who visit from Birmingham.
The layout of the service does its best to help. Separate waiting areas - men downstairs, women upstairs - spare some blushes, as does a self-contained booth where new patients can give their details to reception staff.
There is not much hanging around, either. If they time it right, concerned but symptom-free walk-in visitors - who account for a large percentage of people attending - can turn up, give their details, sexual history and a specimen, then head for the exit in less than half an hour.
"This kind of patient won't need to see a doctor," says nurse practitioner Ray Lewis.
"The nurse or healthcare assistant will take blood samples and get either a urine sample from the men or a swab from the women.
"Providing such a streamlined pathway is important, especially when the clinic is busy. And it keeps us competitive with those high-street chemists that sell self-test kits.
"For patients presenting with symptoms, we can analyse samples here under the microscope," says Mr Lewis. "If something turns up or the history suggests it, the nurse can prescribe or refer them on to one of the doctors. These are just some of the foundations on which we have built to meet the challenge of the 48-hour target."
Test results by text
The Information Shop is a facility for young people, which is based in Bradford city centre and is hosted by the council youth service, the local authority and Bradford and Airedale teaching primary care trust.
Alongside youth workers - who offer information and access to resources such as leisure and bus passes - nurses, health advisers and GPs also provide sexual health sessions. These include advice on contraception, sexual health, sexually transmitted infections and HIV, pregnancy testing, emergency contraception, referrals for termination, a men or "lads" only space and screening for chlamydia. The services are a feature of improving 48-hour access across Bradford and are available over several hours every day of the week except Sunday. With high levels of risky sexual behaviour over weekends identified, opening also extends to bank holiday Mondays.
"It used to be a contraception-based service, but some of the young people would turn up and express concerns about having an STI. We got them appointments sorted with GUM, but a lot of the time they didn't attend. So for about the last eight months we have been able to offer an immediate screening here without wasting a clinic slot," says Bradford council's young people's sexual health strategy manager Claire Whiteley.
"We tend to send both positive and negative results by text. This helps our relationship with young people and reminds them that, even when they get the all-clear, there are still other services here for them."
Clinics must confront surge in most infections
There are currently 208 GUM clinics that offers level three services in England. As well as providing the full range of assessment, testing, treatment and partner notification services - to varying degrees - these centres can also offer specialised HIV treatment and care, specialist infection management and outreach for contraception and sexually transmitted infection prevention.
Only level three services, which provide complex hospital-based care, have been required to return GUM access monthly monitoring data on the 48-hour target. The most recent Health Protection Agency figures on these returns (from August 2007) showed that 86 per cent of patients were offered an appointment within 48 hours. Since the national strategy for sexual health and HIV was published in 2001, diagnoses for STIs in GUM clinics have largely increased significantly between 2001 and 2006. Changes in the diagnoses number for STIs include:
Syphilis - up 375 per cent
Chlamydia - up 57 per cent
HIV - up 56 per cent
Genital herpes - up 14 per cent
Genital warts - up 14 per cent
The only reduction was in gonorrhoea, which fell by 18 per cent.