APPENDIX 35
Memorandum by Directorate, Sexual Health,
Nottingham City Hospital (SH 55)
INTRODUCTION
The Department of Genitourinary Medicine (GUM)
serves a catchment population 600,000 residents of Nottingham
and surrounding districts. It provides a comprehensive service
for the diagnosis and management of sexually transmitted infections
(STIs) as well as being a major regional centre for the provision
of care for HIV infected people. It is the only GUM department
for the city of Nottingham and operates a system of consultation
by appointments as well as open access. Demand for services is
at unprecedented levels, and the department is struggling to cope
with the demands on service due to resource constraints. The resurgence
of bacterial STIs as well as HIV, both nationally and locally
present a number of challenges, especially in the light of the
Sexual Health and HIV strategy (SHS).
WORKLOAD
— Nottingham has the highest incidence
of (STIs) in Trent, and indeed one of the highest in the country.
— During 2001-02, more than 33,000
patients were seen in the department, (17,500 new attendances,
15% above contract).
— During 2001, the department treated
over 700 cases of gonorrhoea and 1,500 cases of chlamydial infection—an
increase of 12% over the previous year.
— The number of HIV infected patients
has risen from 95 in 1995 to 243 as of April 2002.
— The Department operates an appointment-preferred
system but patients with urgent problems may attend on a "triage"
basis. The service is available Monday-Friday with two evening
sessions.
— Due to lack of available resources,
patients with urgent problems can only be seen if they present
themselves within the first hour of clinics.
— The clinic accommodation is inadequate,
demand on examination rooms is high, with patients having to wait
in corridors until one becomes free.
— Any increase in clinical sessions
would require additional manpower resources as well as accommodation.
— The current IT system is unable to
cope with present workload, and is also not geared to provide
the requisite reports and datasets to enable us to plan and utilise
resources efficiently.
ACCESS
— The GUM building was built in 1999
to accommodate the then patient load of 20,000 visits per year.
— The average waiting period for patients
wishing to access the service is 14 days for men and 21 days for
women, the waiting list is increasing to three days per month.
— The existing telephone system is
inadequate to deal with current demands on the service, further
worsening access for patients.
MANPOWER
— Our integrated workforce plan has
shown a considerable deficit in our current workforce, which has
not been acknowledged or funded.
— The service is particularly under-resourced
in Health advisors—the number of cases of gonorrhoea per
health advisor in Nottingham is 166 as compared with 38, which
is the average for other teaching centres outside London.
— Without additional resources, the
department will not be able to support any new initiatives for
screening and management of STIs in primary care as envisaged
in the SHS.
— A review of Specialist Registrar
(SPR) Training by the Regional Education sub-committee in 2000
raised serious concerns regarding the clinical workload and the
ability for consultants to provide quality training and supervision.
QUALITY ISSUES
— Chlamydia screening using neucleic
acid amplification tests (NAAT) is currently funded for certain
primary care sites. We are unable to introduce the same standard
of screening in GUM due to lack of resources.
— Due to the high number of patients,
who must be seen each day, we are unable to give adequate quality
time to these patients. This has serious implications for the
standard of the service and for our continued accreditation as
a training centre for SPRs. Increase in workload, unmatched by
additional resources, is compromising the quality of the service.
— An analysis of medical workload showed
an average consultation time of six minutes for patients with
STIs, and 14 minutes for HIV patients—not commensurate with
the provision of a quality specialist service. This falls well
short of minimum standards recommended by the College of Physicians.
— Increasing dissatisfaction from service
users has resulted in an increased amount of verbal complaints
FUNDING FOR
THERAPIES
— Due to serious cost pressures for
funding HIV treatment (predicted deficit for current fiscal year
£490,000), we are about to have serious restrictions imposed
on prescribing anti-retroviral treatments. This will have serious
implications for the lives of HIV infected people, as well as
catastrophic public health consequences.
— A significant proportion of this
cost pressure is due to treatment provided to out of district
residents and newly arrived asylum seekers who present at Nottingham
for their care. The mechanism for cross charging for out of district
patients is not being implemented.
— Nottingham has one of the highest
rates of unwanted teenage pregnancies. Up to 30% of women under
25 who attend our service are not using any form of contraception.
We are unable to offer contraception to these clients despite
having the staff trained to be able to do so.
INNOVATIONS AND
MODERNISATION OF
SERVICE
— Introduction of Nurse Led Clinics
(NLC) and a Patient Process Redesign project have resulted in
a considerable improvement in the access waiting time as well
as patient experience.
— We have recently appointed a Nurse
Consultant whose role focuses on nurse development as well as
developing integrated care pathways between Primary Care and the
Clinic, so as to ensure a co-ordinated approach to the management
of STIs in Nottingham.
— The role of nurses has been extended,
and the department has a team of trained Nurse Practitioners capable
of providing Level Two care in readiness for the implementation
of the SHS.
— Integrated working between GU medicine
and primary care—a model that is regarded as a example of
good practice within the specialty.
STAFF DEVELOPMENT
Despite of our work pressures, we have introduced
the following measures to improve recruitment and retention, as
well as improve staff morale:
— The implementation of a Clinical
Governance framework involving all grades of staff.
— Introduction of a policy of Shared
Governance through the formation of four staff forums, which ensures
that staff of all grades are able to contribute to the decision
making process within the department.
— The development of a comprehensive
induction and in-service training programme.
— Annual staff satisfaction survey
as well as IPRs and PDPs
TRAINING
— There has also been a reduction in
the time available for teaching medical students who now attend
for only two sessions in the GUM clinic.
— Poor staffing levels have reduced
training and liaison opportunities with key local professionals,
including social workers, residential care workers, and school
nurses and youth workers.
— Senior nurses are restricted in the
time they can give to teaching outside of the department, and
in offering placements to pre-registration and post-basic students.
FUNDING
— Trent Region receives below the national
average per-capita funding—Nottingham per-capita funding
is below average for the Region.
— During the last five years there
has been over 45% growth in activity without any new investment
in the service
— With the introduction of new Strategic
Health Authority, there is a lack of clarity on who is responsible
for commissioning for HIV services.
— Access to capital funding is impossible
as sexual health is not on the Government list of priorities for
health care.
SUMMARY
— GUM service in Nottingham is seriously
under-resourced in relation to the workload and the prevailing
rates of STIs and HIV in the community.
— There is good evidence for innovative
practice, especially nurse development as well as examples of
good practice between primary and secondary care sectors.
— Waiting time for patients wishing
to access the service is unacceptably long.
— Quality of service is below minimal
acceptable standards.
— Patient care is being compromised.
— Training of junior doctors and nurses
is being compromised.
— Increasing dissatisfaction from service
users resulting in an increased amount of verbal complaints.
— All the above areas of concern were
highlighted in an external independent service review commissioned
by Nottingham Health Authority in September 2001 (copy of report
and support documentation available).
— The service will require significant
new investment to enable it to support the implementation of the
SHS.
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