Memorandum submitted by Dr Pat Munday
(SH 51)
I would like to present a "case history"
of the development of one sexual health service on the edge of
the London conurbation to illustrate how changes in policy and
funding have impacted on the service.
— In 1989, I was appointed Consultant
Genitourinary Physician to Watford General Hospital. At that time,
the service was housed in unsuitable accommodation and operated
four half days a week.
— Subsequently, the Monks report and
the advent of AIDS development money allowed us to build a new
department at the front of the hospital.
— The site and facilities were in part
determined by a survey of patients—one of the first examples
of such surveys in the NHS and the first to be published from
a GUM Clinic. We have continued to survey our patients at regular
intervals and have used the results of such surveys to influence
service developments. For example we ran two evening, one early
morning and one lunch-time clinic to accommodate the needs of
our patients.
— Our choice of site was influenced
by a view that, if the service were to be destigmatised, it should
be visible. Our support charity subsequently chose the name "Upfront"
and we have been evangelical about sexual health services.
— Between 1991 and 1995, patient attendances
increased steadily; our female to male ratio increased, reflecting
our desire to encourage the attendance of female patients for
screening. We started to see HIV positive patients, though in
small numbers. We increased our staffing to meet service demands
and opened new sessions so that the Department opened every weekday.
All services were open access ; ie we saw all patients who chose
to present themselves during the advertised opening hours.
— In 1994, because we were concerned
that we were seeing too few young patients (who were known to
be at particularly high risk of STIs) we set up a multipurpose
clinic for under 20 year olds. The name "Awareness"
was chosen after collaborative work with a local higher education
college and was tested in field work with the General Public.
The "Awareness" Clinic offered a full contraceptive
and GUM service, together with counselling, support, HIV testing,
pregnancy testing, and more recently, a dietician. All staff are
dually trained in GUM and family planning. This clinic, which
was set up without additional funding, remains one of the few
truly integrated "one stop shops". Interestingly, following
the development of "Awareness", we started to see considerable
more young people in our routine clinics, a reflection on the
confidence which young people had in the service in general.
— During this period we also developed
outreach teams. We had three workers, one working with gay men,
one with young people and one with ethnic minorities. We also
acquired an HIV social worker (funded by the AIDS support grant)
and an HIV dietician (both part-time). These new posts were largely
funded by designated "AIDS money". We developed psychosexual
services, a specialist service for genital skin problems, and
regular audit programmes, which involved all members of the team.
We conducted a number of small research studies and published
the results.
— In 1995, we outgrew our clinic premises
and were successful in a bid to extend the Department by 50 per
cent to add a floor, mainly for counselling and support services.
This was the last tranche of AIDS money.
— Since 1995, clinic attendances have
continued to increase. Additional costs were met within budget.
In particular no additional funding was obtained for the costs
of managing the increasing numbers of HIV positive patients, although
from 1998 the costs of antiretroviral therapy for newly diagnosed
cases were met by the Health Authority.
— In 1998 we were awarded a Chartermark,
one of the first GUM Departments to succeed in obtaining this
award.
— We started work to bring together
the sexual health services in West Hertfordshire. On 1 April 2001,
a new sexual health directorate comprising two GUM clinics, seven
community family planning clinics, outreach and health promotion
teams was established under a single management structure within
the Acute Trust. Shared staffing, joint meetings and a single
Clinical Governance lead have helped to strengthen links and hopefully
to facilitate joint working as envisaged by the Sexual Health
Strategy.
— By 1999-2000 the Department had reached
maximum capacity and was seeing as many patients as could be physically
accommodated with the available staff (3.4 wte doctors; 5.15 wte
nurses 1.8 wte health advisers).
— In January 2001, the number of clinic
attenders was 35 per cent more than in the previous January. The
evening sessions were overwhelmed and the staff demoralised. It
was impossible to give a quality service any more. The senior
nurse, a health adviser and an outreach nurse resigned. Another
nurse developed an injury, which led to long-term sick leave.
Another outreach worker was already on long-term sick leave.
— The Trust Chief Executive was informed
of the situation. Transitional funding was sought to allow the
service to continue. No response was received for several weeks;
the papers were then passed to a senior manager who appeared to
have no ability to make financial decisions. The Director of Public
Health was also informed; he responded after several months to
say that he did not think the situation was exceptional. It was
not possible to identify anyone in the Health Authority who could
offer any suggestion. Fledgling links with PCG/PCTs which had
been developed over the previous couple of years proved to be
fragile and it was impossible to obtain PCG/PCT representation
at meetings of the local sexual health steering group which had
been set up.
— The serious situation was brought
to the attention of the Clinical Management Board who supported
a bid for a new Consultant. It was felt that a new consultant
was essential, not only because of the increasing workload but
because there was a need for additional senior leadership to deliver
the Clinical Governance agenda. However this bid was thrown out
in the SAFF round as being of low priority to the local health
economy as a whole.
— Internal changes were made; the outreach
team was de facto disbanded. One post was used to fund
a locum consultant post, but it was not possible to fill this
for several months. Another post was converted into a health adviser
post. Several changes in the way the service was delivered were
made.
— Throughout the summer of 2001, for
the first time in the history of the service, it was necessary
to close clinics on an ad hoc basis as they could not be staffed.
Attempts to recruit to the various posts failed (this is a particular
problem in this location, as it is very close to the boundary
of the area where staff get full London weighting allowance; however
housing costs etc are just as great as over the border in Greater
London). Despite the closures, we saw almost as many patients
in 2001 as in 2000. There was also a large increase in the HIV
workload, in part because of the introduction of antenatal testing.
It should be noted that we have no specialist HIV doctor in either
clinic in the Trust, with a workload now of around 100 patients.
These patients are just seen along with all the others whenever
possible.
— In October 2001 we recruited to the
locum consultant post; the post was however shared with the GUM
Department at St Albans (within the same Trust) and therefore
is only half time. No additional money was given, so the funding
lasted for six months; as a new financial year started in April
2002, we could continue the post for six months of this financial
year only. A bid for a new consultant was again submitted. Although
this is still pending, it seems unlikely to succeed. The locum
consultant, after five weeks, wrote to the Clinical Director expressing
her anxiety that the service was unsafe and needed considerable
extra resources to match the clinical workload.
— We did eventually receive funding
for one D grade (junior) nurse but no other resources.
— In April 2002 the situation was again
brought to the attention of the Clinical Management Board. The
Board said that no additional resources would be made available
and that services should be cut to a sustainable level. It should
be stated that this Trust has had severe financial problems for
the best part of the last 10 years. A suggestion has been made
that the sexual health budget should be cut by £200,000 (this
would require closing almost all of the community family planning
clinics, for example).
— In June 2002, we introduced a new
timetable which will be based largely on appointment clinics and
was intended to restrict access to approximately two thirds (about
12,000) of the patients we are currently seeing. This will mean
long waits for screening, HIV testing etc. As we are committed
to the principle of open access, we have retained two hours of
open access clinics daily. These clinics are restricted to new
patients and those with acute problems. Controlling access required
the presence of a nurse or health adviser to conduct triage. This
takes away a member of staff from the small pool available for
seeing patients.
— After four months experience of the
new timetable, we are still seeing approximately 15 per cent more
patients than during the same period in 2001. However, there have
been considerable difficulties in moving to an appointment system
as there were inadequate staff and phone lines to receive requests
for appointments. This has led to considerable abuse of staff
and our first formal complaints with regard to service provision.
No additional funding was available from the Trust to support
the transition.
— Although we believe that the current
system is more equitable, there are unsustainable pressures on
staff which I believe will lead to more staff losses and further
difficulties in recruitment. Three attempts to replace a junior
nursing post in the last year have been unsuccessful.
— Although the new money which has
come to us as a result of the sexual health strategy is helpful,
it goes only a little way to meet the difficulties. In particular
there is a need for it to be explicitly recurrent funding as the
Trust will not agree to any new appointments if there is any risk
that additional funding would be needed in the future from Trust
resources. This means that our much needed new consultant post
remains unsupported.
CONCLUSIONS
A very successful, highly respected service
was established in West Hertfordshire by the middle of 1990s.
The service had anticipated and implemented many of the ideas
in the Sexual Health Strategy. No significant additional funding
was obtained after dedicated AIDS funding ceased. The Trust has
severe financial problems and is prioritising meeting current
Government targets. The Trust has made it clear, that as there
are no targets currently attached to sexual health, there will
be no additional resources, even when there are issues around
clinical governance. Indeed, budgetary cuts are anticipated. The
Trust's response to the increasing clinical workload is to reduce
services. As a result of this many of the successful innovations
of the last decade, such as an outreach service and open access
evening/ early morning clinics will be sacrificed to maintain
a core clinical service.
November 2002
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