APPENDIX 5
Memorandum by Brighton GUM/HIV Clinic
(SH 11)
EPIDEMIOLOGY
1.1 We write on behalf of the Brighton GUM/HIV
clinic as representatives of the consultant body and multidisciplinary
team. The clinic in Brighton is essentially the monopoly provider
serving an immediate population of 250,000, although this swells
to over 1 million during the summer months. The population has
a large and vibrant gay community and two large universities—hence
we see a disproportionate amount of STI's including HIV.
1.2 Over the last four years the number
of GUM attendences has increased from 15,286 to 21,040 (38%).
Over the same time period the incidence of STI's has increased
as follows: Chlamydia 318% (prior to the use of the more sensitive
nucleic acid amplification test), gonorrhoea 199% and syphilis
by over 700%, Brighton being one of the locations of the current
and ongoing syphilis outbreaks.
1.3 Over the same time period the number
of HIV positive patients under regular follow up has risen from
476 to 782 (64%) and the number of new diagnoses continues to
increase (101 in 1999, 135 in 2000, 129 in 2001, 60 in 2002 so
far to end April). As in most treatment centres the complexity
of HIV care continues to increase with 70% of our patients currently
receiving HAART.
1.4 In addition although the surrounding
towns of Crawley and Redhill are within West rather than East
Sussex we have, by default, and because of established transport
links, provided inpatient and outpatient HIV care for a further
100 additional HIV patients. Many of these patients are asylum
seekers and as such have complex medical and social needs.
FUNDING
2.1 Over this three year time period the
level of funding for staffing and infrastructure has failed to
match the changes in activity.
2.2 We have been fortunate in fostering
close links with the former East Sussex Brighton & Hove Health
Authority which has enabled the appropriate allocation of funds
to support anti-retroviral (ARV) drug costs in accordance with
BHIVA guidance, however we await the transition to PCT/strategic
HA commissioning with some anxiety. We have concerns that the
costs associated with the responsible provision of ARV's are greater
than the drugs alone and medical, pharmacy and adherence support
services need to be allowed to expand in tandem.
2.3 During this enormous increase in activity
funding for staffing of GUM/HIV clinical services has increased
by: consultant staff 0.5 WTE (increase of 10% to current complement
of 4.5), non-consultant medical staff 0 WTE, nursing staff one
WTE (10% increase to current complement of 10 WTE), health advising
staff 0 WTE, administration and clerical staff two temporary posts
for one year (22% to current complement of 11 WTE)
2.4 There has been no additional funding
for GUM or HIV outpatient departments and we operate from the
same premises that were allocated in 1994. This has markedly reduced
our ability to work in a more efficient or innovative fashion
and provides an environment that is not conducive to high throughput
and increases patient dissatisfaction during prolonged waiting
times.
CURRENT SERVICE
DIFFICULTIES
3.1 Over the last 12 months pressures in
the Brighton GU clinic have reached a level where clinics over-run
on a daily basis. Since no additional funding has been forthcoming
to allow an increase in staffing, we have reluctantly had to curtail
services. Rather than planning innovative and far-reaching policies
for local sexual health improvement in line with the sexual health
strategy, from February this year we have restricted walk-in opening
hours to 3 pm, with consequent negative effects on teenage access
in particular. Cutting services is in complete opposition to the
proposals of the sexual health strategy and in the face of a rapid
increase in demand is highly unsatisfactory.
3.2 Until recently patients have not been
turned away, however we are now turning patients away most weeks
due to overwhelming demand. Despite serious reservations we have
finally decided that in order to maintain service quality, patient
safety and staff moral that as of next month we will limit the
walk-in nature of our service which will again have a detrimental
impact on the sexual health of the local population.
3.3 GUM/HIV services in the past have always
benefited from good staff recruitment and retention. Unfortunately
this position has recently reversed in our clinic—as a direct
consequence of working conditions 70% of the combined nursing
and health advising team have left in the last six months and
we have witnessed a 300% rise in staff sickness.
3.4 To further reduce the number of patients
accessing the clinic we are reluctantly considering giving results
over the telephone, including HIV results. Whilst this may help
with actual patient numbers we are concerned it will result in
a further decline in service quality, loss of opportunities for
effective health promotion and potential increase in patient anxiety.
3.5 Due to increasing demand without a parallel
growth in resources the waiting times for new HIV appointments
has increased from two to six weeks. As many patients present
with advanced disease requiring immediate assessment and support
this is clearly unacceptable.
3.6 The success of the sexual health strategy
depends to a large extent on establishing links with primary care.
Whilst we are keen to develop locally agreed protocols, take part
in education and training, design care and referral pathways,
ensure clinical governance at all levels, develop frameworks for
monitoring and improving practice, we are currently unable to
provide such support and have no capacity to expand links in the
way we would like.
SUGGESTED IMPROVEMENTS:
4.1 We feel locally that we have exhausted
all attempts to work more efficiently within existing resources.
With on-going demand on an already stretched GUM/HIV service we
foresee a progressive fall in quality of care and would recommend
urgent investment in staff and capital. Fundamental to this would
be a process of stocktaking to ensure equity of funding for GUM/HIV.
4.2 We would strongly endorse a system of
funding linked to activity with agreed service specifications
for GUM services and a commitment from the PCT commissioners to
maintain an open access service which we see as crucial to tackling
the on-going increase in STI's and HIV in our community.
4.3 In HIV the major issues are similar
in terms of manpower and resources but also in the way HIV is
funded. This has particular relevance in Brighton with regard
to the extra workload derived from West Sussex. We would recommend
a robust, fair, timely system of cross-charging and increased
support to promote the development of managed clinical networks
for HIV across Sussex.
4.4 The Brighton HIV clinic is one of the
largest HIV service providers in the country but suffers from
being excluded when service reviews focus on HIV care in the capital.
This could be addressed by a long overdue review of non-London
HIV service provision with a proportionate increase in out-of-capital
funding
Overall we are an enthusiastic committed department
and we welcome the suggestions made in the sexual health strategy
for providing exciting and innovative ways of working. We must
however be realistic about what can be achieved within existing
resources and ask you to consider the above points carefully.
June 2002
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