APPENDIX 8
Memorandum by Dr Janette Clarke (SH 16)
DECLARATION OF
INTEREST
Please note this submission is as an individual
clinician.
I am Honorary Treasurer to the Association for
Genitourinary Medicine but the views expressed in this submission
are my own and should not be attributed to the organisation.
During the development of the Sexual Health
Strategy, Professor Michael Adler interviewed me in my role as
a clinician working in a District General Hospital.
PERSONAL BACKGROUND
I am an accredited hospital specialist in genitourinary
medicine, which is the medical specialty in the UK dealing with
the prevention, detection and treatment of sexually transmitted
infections including HIV. I am clinically responsible for both
inpatient HIV and outpatient HIV and sexual health services.
I practiced as a consultant to Pinderfields
and Pontefract Hospitals NHS Trust to the end of November 2001
for a total of some 10 years; in the first eight years I also
provided care at Dewsbury District Hospital. From November 2001
to the present, I have held an appointment as consultant in genitourinary
medicine in the Leeds Teaching Hospitals NHS Trust. My personal
service interests include the development of young people's sexual
health services, integrating sexual health services and nurse-led
service development. My research interests include investigative
methods for diagnosing infection in the context of sexual abuse
and assault. I have been an expert witness in the development
of national guidelines for managing contact tracing in genital
chlamydial infection.
SUMMARY
The Sexual Health Strategy is welcomed, provided
it delivers equal access to healthcare of a standard quality at
all levels. Concerns around the interim provision of genitourinary
medicine (GU Medicine) are expressed, with particular reference
to patient access and experience of outpatient care. Discussion
of possible barriers to implementation follows, and suggestion
of amended targets for provider Trusts is offered.
1. The overall strategy is a welcome advance
in offering a patient-centered approach to this area of healthcare.
The massive workload that such a systematic approach will bring
to all clinical levels of care needs to be addressed. In particular,
extension of HIV testing targets and chlamydia screening will
put huge burdens on the clinical services. There is little discussion
in the document on how we step from the current system to the
new network, and no commitment of funding to the clinical service
towards this transformation.
2. I am seriously concerned about the impact
of these factors on levels of patient care. Our young people are
more aware of the need for screening and testing in sexual health,
and so demand for open access appointments has increased. Non-specialists
are referring more patients and their partners. People with HIV
infection require regular monitoring and complex therapies; the
success of the therapy combined with increasing new diagnoses
means more appointments are needed for HIV care. An increasing
proportion of our patients require interpreters and such interviews
take much longer than average appointments.
3. All of these demands have been put on
a clinical service without significant development for over 10
years. In my clinical practice over this time, I have seen strenuous
efforts by all members of the clinic team to keep access open
for new and re-registering patients needing screening in GU medicine.
Initiatives such as nurse-led clinics and patient-held therapy
have cut down on return visits, but they have had a limited effect
in recent times since the scope of change diminishes. Doctor sessions
are now more intensive in terms of demand for skilled nurse input
for slide interpretation, venepuncture and dispensing. The staff
shortages at all levels mean that developmental initiatives are
seriously restricted because of the heavy service burden. Outreach
services such as partner notification for primary care, community
visits and training for non-specialist staff have been abandoned
to concentrate on providing service.
4. The practical effects are predictable.
The outpatient clinics are crowded, and patients cannot arrange
an appointment or walk in to a service in a time they feel relevant
to their problem. I am faced with patients every working day who
grumble they had to wait two or three weeks to have their appointment;
this interval is just too long for acute communicable disease.
The crowded clinics despite the waiting time show that people
appreciate the care, and once seen, the comments we receive are
very complimentary.
5. Sexual health clinics are one of the
front doors of the health service. Our young patients, sometimes
making their first independent health-seeking choice, need a confidential,
low profile, non-judgmental and friendly atmosphere for the service.
These characteristics are typical of the current GU medicine services
and will need to be developed in the three-tier service characterised
in the Sexual Health strategy. If our clientele are given an unsatisfactory
experience through lack of resources and staff it may colour their
opinion of the health service as a whole.
6. Practice changes should be invisible
to the patient; the user of the service should receive the same
basic quality of care wherever they are seen.
7. There appears to be some legal and practical
barriers to this at present; for example, I believe free prescriptions
for all infections are not available in primary care. Clinical
governance of independent contractors such as general practitioners
by hospital consultants is also an area for practice development
expected in the strategy, but not usual at present. Primary care
teams need to be encouraged to develop their basic sexual health
services through education and financial targets, but these are
largely unavailable at present. I would urge a review of the legal
implications for primary care of the strategy.
8. I understand the waiting list for attending
GU medicine is not formally included in Trust statistics, but
the current timescales for general outpatients are not relevant.
However, we represent a significant proportion of a Trust's outpatient
service to the community. Targets such as appointments available
within five working days would be appropriate. Since we fail to
feature on National Service Frameworks and other national targets,
it is not surprising that we are not seen as a development priority
at present. I would urge consideration of development of a NSF
for sexual health with appropriate funding.
9. The sexual health strategy offers a vision
of comprehensive open access service for HIV, sexual infection
and contraception services. I sincerely hope we can work towards
the vision, but would plead that patients need services in the
interim.
June 2002
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