APPENDIX 20
Memorandum by Dr Linda Green (SH 32)
1. INTRODUCTION
I am writing in my capacity as Lead Consultant
for the walk-in GUM/Sexual Health Clinic at St Mary's Hospital,
London. I am delighted that a Health Committee Inquiry into Sexual
Health and HIV services and the National Strategy for Sexual Health
and HIV has been convened and to have this opportunity to submit
evidence from our day-to-day experience at St Mary's. A separate
response specifically dealing with HIV services is being submitted
by our Lead Consultants for HIV.
2. ACTIVITY
The Jefferiss Wing Centre for Sexual Health
at St Mary's has one of the busiest GUM clinics in Central London.
It has always operated as a completely open access walk-in clinic
and is open for walk-in patients for more hours per week than
any other clinic in London. We have experienced a 25% increase
in walk-in clinic activity over approximately five years. Despite
this background of ever increasing activity in line with National
trends, we have been taken aback by recent massive increases in
demand for services. For the first time I can remember, we have
daily queues of 30 to 40 people outside the clinic for up to an
hour before we open. We believe that these recent increases are
being fuelled by the very real increases in acute bacterial STIs,
increased public awareness as a result of the recent media focus
on STIs and, unfortunately, by changes in the access policy of
other London GUM clinics. As a consequence of this increased activity
waiting times in the clinic have rocketed and staff morale has
been badly affected. During March 2002 staff were regularly finishing
work at 9.30 pm or later Monday to Thursday. This was in spite
of the fact that we have no significant reception, nursing or
medical vacancies or sickness absence and use all available clinical
space at all times. As a result of this unsustainable increase
in activity we introduced a system of early closure of the walk-in
clinic in late March. This was a difficult and painful decision,
as we strongly believe in the principle of maintaining open access
walk-in GUM services. As one of my colleagues often says "you
can't always plan your sexual encounters and you certainly can't
plan your STI". However, there were clear indications that
we would imminently lose nursing and reception staff if we did
not take action and that the quality of the clinical care we were
offering was beginning to be adversely affected. Despite taking
this action, we saw 20% more walk-in GUM patients this April than
in April 2001 and there is no indication of any decline in activity
in May. These increases in activity over the last five years have
not been matched by increases in funding or investment in infrastructure,
manpower or proposed service developments to cope with demand/patient
need. We will not be able to cope with the inevitable increased
demand for services as a result of the planned National media
campaigns later this year.
3. ACCESS
Access to GUM services in London is deteriorating.
In the last 12-18 months, six out of eight of the other GUM clinics
in the North West London Sector of which we are part have changed
their access policy away from predominantly walk-in to a predominantly
appointment or appointment only system. Their reasons for doing
so are understandable; they too are unable to meet current demand
for services and are struggling with issues of capacity and manpower.
However, the effect on St Mary's has been dramatic and has played
a major part in our own recent restrictions on access. Individuals
with symptoms of an STI or very reasonable concerns that they
may have or have been exposed to an STI are being turned away
from clinics. Every time I do a clinic I see patients who have
come to St Mary's as a last resort having being turned away from
their local and/or their usual clinic of choice. Recently, this
included a young gay man, HIV status unknown, who thought he had
primary syphilis. He had been turned away by two central London
clinics and had waited four hours to be seen at the Jefferiss
Wing. How many young gay men with possible HIV and/or infectious
syphilis would have given up after being turned away at the first
clinic? How many more individuals could be infected as a result?
Maintaining and improving access and increasing capacity is crucial
if existing services are to have any chance of dealing together
with outbreaks of STIs such as the ongoing epidemic of syphilis
amongst gay men. I do not believe that the Draft Strategy for
Sexual Health and HIV addresses issues of current access to GUM
services adequately; it is easy to confuse self-referral with
open access; what individuals with or at risk of STIs [or unwanted
pregnancy] want and need is walk-in/same day access services.
There will be a public and media outcry if individuals motivated
by National educational/media campaigns to attend a GUM clinic
for STI screening/HIV testing find themselves unable to access
local services.
4. PSYCHOSEXUAL
SERVICES
The Jefferiss Wing has a dedicated specialist
multidisciplinary sexual function service, The Jane Wadsworth
Clinic. This clinic attracts patients from all of London as well
as outside London. There is currently a six month wait to see
a consultant in this clinic. Disorders of sexual function are
common and at present are poorly addressed by the NHS. The Sexual
Health Strategy rightly addresses the need for the development
of dedicated services but fails to address how they should be
funded. We currently receive very limited funding, which partially
covers the cost of prescribing Viagrag and other drugs but most
GUM clinics are unable to secure any specific funding and therefore
provide very limited or no services for affected individuals.
5. ENVIRONMENT
AND CAPACITY/MANPOWER
In common with many other GUM clinics, our facilities
are in dire need of upgrading and are full to capacity. All available
clinical space is used all the time and waiting rooms are frequently
overcrowded, hot and as a consequence smelly. These conditions
are very unpleasant for our patients and do nothing to combat
the stigma they already feel. We have introduced a number of innovative
practices and systems over the years at the Jefferiss Wing, including
a nurse led follow-up clinic suite, to avoid unnecessary repeat
walk-in clinic attendances by patients. We are now unfortunately
in the position of being unable to introduce any further efficiency
measures to reduce waiting times, increase throughput and thus
improve the patient experience due to a critical lack of space
and manpower. The Draft Sexual Health Strategy is commendable
in its plan to improve access in the long term by increasing the
role of Primary Care. However, existing GUM services will continue
to see ever increasing numbers of patients for the foreseeable
future and there is an urgent need for significant investment
in our infrastructure and manpower if collapse of GUM services
is to be averted.
6. TRAINING AND
CLINICAL GOVERNANCE
The Draft National Strategy for Sexual Health
and HIV places responsibility for training and Clinical Governance
for all proposed levels of sexual health services with Level three
service providers [current GUM and Specialist Contraceptive services].
I do not think that any consultant would argue with this in principle.
However, in the current climate I am finding it difficult to maintain
the quality of training and supervision I give to staff working
in my own department, let alone take on responsibility for staff
working in our local Primary Care Trust. I am the Lead Consultant
for Clinical Governance for GUM/HIV and over the last six months
have had to deal with more incidents where our highly developed
quality control measures have failed than at any time in the last
two and a half years. In the majority of cases, human errors have
occurred due to pressures of workload. We cannot be expected to
keep seeing increasing numbers of patients without investment
to support high quality clinical care. Consultants in GUM are
not going to be able to oversee education and Clinical Governance
in Primary Care unless their current workload is addressed and
the necessary expansion in consultant numbers has occurred.
7. COMMISSIONING
AND FUNDING
ARRANGEMENTS
In my experience as a consultant [since January
1999], attempts to strategically plan and develop our services
to respond to increases in activity and patients' needs have been
thwarted by the short-term approach taken by commissioners. This
in large part has been due to the uncertainty over the last few
years regarding the future of Sexual Health and HIV funding and
commissioning arrangements. As a result very few of our bids to
improve and develop Sexual Health and HIV services have been funded.
Now that the commissioning arrangements have been finalised, and
it is clear that Primary Care Trusts have responsibility for commissioning
GUM services, we are faced with the news of no increase in funding
for GUM above inflation in 2002-03 and a Commissioning Organisation
that hasn't yet fully established its Board and has no formally
nominated Lead for Sexual Health. Whilst there are definitely
encouraging signs of interest from individuals and some genuine
first steps towards partnership working, there appears to be little
chance of influencing funding decisions in this financial year.
I am not sure that our and many other GUM services can withstand
another year without significant investment and I think this is
borne out by the crisis in access and our failure to have any
impact on rising STI rates. Additionally, there is no mention
in the Draft Sexual Health Strategy of targeted funding to enable
GUM services to achieve the targets set out in the document—HIV
tests are, after all, not free.
8. THE GP PERSPECTIVE
It is my impression from talking to a number
of GP colleagues, both locally and in other parts of London, that
level 1 services as set out in the National Strategy will not
be easy to achieve. Those that I have spoken to have been the
motivated individuals with an interest in Sexual Health who have
self-nominated to local Sexual Health Working Groups or been the
first to come on the STI Foundation Courses. Despite their enthusiasm
they have largely left me with the view that raising awareness
and testing for STIs in primary care will inevitably result in
increased referrals and workload for existing GUM services. The
proposed shift of "routine" Sexual Health/STI diagnosis
and care to Primary Care will not be achieved for many years and
will require substantial investment in Primary Care Teams. It
is vital that in the interim existing GUM services receive the
political and financial support they will need to continue to
provide high quality responsive services to increasing numbers
of individuals.
9. THE PATIENT
PERSPECTIVE
I hope that I have illustrated above that being
a prospective GUM clinic attendee in London in 2002 is not a pleasant
prospect. First of all you have to negotiate the intricacies of
your local GUM clinic's access policy and "if at first you
don't succeed, try, try again". We hope. Unfortunately, we
know that those most at risk, the young, the socio-economically
deprived, the teenage mum with no back-up child care, are the
least likely to adopt this approach and their STI will go untreated
a little or perhaps a lot longer. Once you've managed to access
a service, queued with strangers for 30 minutes worrying if you'll
see anyone you know or your mum's friend who works at the hospital,
you may then face a long and unpleasant wait in a hot, probably
cramped, waiting room. Fortunately, at the end of this process,
you'll be seen by caring, knowledgeable professionals who'll do
all they can to give you the highest quality advice and care available
to the best of their ability within time constraints enforced
by overwhelming and unprecedented activity levels and within their
clinics budgetary constraints. The National Strategy sets out
an agenda to reduce the stigma associated with STIs and HIV and
improve the patient experience. I think we're doing all we can
already—what's needed now is investment in services to improve
access and respond to increased activity.
10. SUMMARY
I hope I have set out above the view from a
busy genuinely open access GUM service at the front-line of STI
care in Central London and that this informs your discussion,
conclusions and recommendations. I support a National framework
for Sexual Health and HIV but fear that the Strategy in its current
format does not address what is in essence a current make or break
crisis facing GUM services. In common with many working in the
Specialty I call for the Government to develop a National Service
Framework for Sexual Health and HIV—without this and the
political and financial commitment that would come with it I feel
access and services for patients will further deteriorate.
June 2002
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