APPENDIX 50
Memorandum by Dr Belinda Stanley (SH 79)
Single-handed consultant, large rural area;
Graduated Southampton 1982;
Consultant Appointment 1989;
Northern Association for Genito Urinary Medicine
peer review co-ordinator;
President elect local BMA division;
Appointed member Fitness to Practise Committees of
the GMC;
Chair local research ethics committee.
SUMMARY
1.Attendances at departments of Genito urinary Medicine
continue to rise.
2.There is an increase in incidence of sexual transmitted
infection.
3.Waiting times for appointments in Genitourinary
Medicine departments are increasing.
4.Triage policies may fail to give access of care
to the needy.
5.Changing practices have reduced review patient
to new patient attendance ratios.
6.Future development of nurse lead clinics is compromised
by the history of financial savings being made by removing trained
nursing staff from clinics and replacing with nursing auxiliaries.
7.Increasing workload has led to a reduction in quality.
8.Removal of HIV funding ring fencing has led to
virement of money and reduction of available clinical support
for prevention initiatives and treatment and care.
9.Reorganisation of Strategic Health Authorities
without regard to geographical distance has led to commissioning
problems with respect to tertiary care, medical student training,
medical staff training, etc.
10.Lack of national service frameworks gives PCTs
and Trusts no impetus or imperative to develop or maintain service
levels.
11.Proposed collection of post code data for epidemiological
mapping of infection is impractical without financial support
for information technology systems.
12.Proposed collection of post code data for epidemiological
mapping of infection may give data that are difficult to interpret
as patients may give false names and addresses.
13.Single-handed practitioners supporting junior
medical colleagues [clinical assistants] and providing to offer
and support by telephone to geographically distant clinics, rather
than giving on site support may have difficulties in defending
themselves or their staff in the event of a patient complaint.
14.Patients' reluctance to complain in rural areas
because of associated stigma may give an inaccurate impression
of satisfaction with the service being tendered.
15.Single-handed practitioners providing support
for HIV emergencies, needlestick injuries, and STD emergencies
cannot comply with the E U working times directives.
16.Implementation of consultant appraisal and five-yearly
review will be difficult without reducing opportunity for patient
access to services unless funding levels increase.
17.From a low starting point in 1989 patient numbers
with HIV have increased locally 20 fold.
18.Support from consultant colleagues with an interest
in HIV medicine is reducing because of fears of medical litigation
and in response to GMC guidelines as the complexity of HIV management
increases.
19.Although access to HIV specialist care may be
available at geographically remote specialist centers, acutely
sick patients may be too ill to transfer. District hospital physicians
must be supported by their specialist colleagues.
20.Support and training for Single-handed to Genitourinary
medicine definitions in rural areas is observed more in theory
than in practice as attendance at training meetings may be impractical
considering geographic distances to be covered .
21.Some targets of the National Sexual Health Strategy
may be achievable in some areas. New patient HIV screening may
be achievable, targets for completed Hepatitis B vaccination are
unlikely to be achieved and may be more appropriate for general
practice because of the episodic access to care in the former
and continuing clinical responsibility in the latter
22.Integration of family planning, general practice
and Genitourinary medicine will compromise current levels of patient
confidentiality.
23.Developments in clinical testing offer patient
advantages. (Chlamydia PCR testing.)
1.Attendances at departments of Genitourinary Medicine
continue to rise.
New patient numbers have increased by over 300% in
the 12 years since my appointment without corresponding increase
in clinic funding or access time.
2.There is an increase in incidence of sexual transmitted
infection.
This is recognised from national data collection.
Presence of genital inflammation increases the efficiency of transmission
of HIV infection, hence the need for rapid access to treatment
as those waiting for an appointment to be seen do not necessarily
refrain from sexual intercourse.
3.Waiting times for appointments in Genitourinary
Medicine departments are increasing.
This is as a result of both one and two but may also
reflect patient concerns about confidentiality in General Practice
or increasing concern about sexual health.
4.Triage policies may fail to give access of care
to the needy.
Studies from Southampton have suggested that although
triage systems may be in place, getting past a receptionist who
does not have time and/or medical skills for telephone medical
consultation may mean that patients in urgent need fail to be
seen at the appropriate time.
5.Changing practices have reduced review patient
to new patient attendance ratios.
In an attempt to free more clinic time to respond
to demand we have increased our use of home therapy (HPV) and
home testing (Chlamydia PCR). Review patient/ new patient ratios
have reduced from 1.78 in 1991-92 to 0.89 in 2001-02 Telephone
consultations are increasing. This affects the clinician/patient
relationship and gives an increasing risk of medical litigation
(difficulties about confirming patient identity etc).
6.Future development of nurse lead clinics is compromised
by the history of financial savings being made by removing trained
nursing staff from clinics and replacing with nursing auxiliaries.
Originally clinics were staffed by two trained nurses per doctor
per clinic session, financial savings have been made by reducing
this to one auxiliary nurse per doctor per clinic session. This
leaves almost no scope for the development of nurse led clinics.
7.Increasing workload has led to a reduction in quality.
Increase in time to new appointment, reduction of skilled nursing
support, reduction in average time spent with patient, reduction
of review of patients after treatment, increase in telephone consultation
led by appointment availability pressures rather than patient
request or need, reduction in availability of appointments
8.Removal of HIV funding ring fencing has led to
virement of money and reduction of available clinical support
for prevention initiatives and treatment and care. Local prevention
initiatives and staff numbers dealing with them have been allowed
to fall due to "natural wastage"—staff posts vacant
are not refilled. This has also happened with access to psychological
services locally.
9.Reorganisation of Strategic Health Authorities
without regard to geographical distance has led to commissioning
problems with respect to tertiary care, medical student training,
medical staff training, etc. It is inappropriate for those commissioning
care to be from a region based in the North West when patient
preference for tertiary care for HIV, Hepatitis C is for access
to care in Newcastle, Northern Region. How can Manchester commission
or be committed to provision of tertiary care from a different
region. How can I have any influence in the planning or provision
of services that my patients may use if these are in a region
that is geographically separate. Why should Northern region feel
any responsibility for providing me with cover, support, patient
service etc if they are not funded for this care. This increases
my feeling of isolation as a single-handed consultant in a rural
area. Similar problems are experienced by other specialties but
are outside the scope of this submission.
10.Lack of national service frameworks gives PCTs
and Trusts no impetus or imperative to develop or maintain service
levels. There are so many imperative targets and NICE guidelines
that a specialty without long waiting lists, no national targets,
with patients who are reluctant to complain and are more likely
to be socially disadvantaged. Competition for funding in this
context is severe.
11.Proposed collection of postcode data for epidemiological
mapping of infection is impractical without financial support
for information technology systems.
12.Proposed collection of post code data for epidemiological
mapping of infection may give data that are difficult to interpret
as patients may give false names and addresses.
13.Single-handed practitioners supporting junior
medical colleagues [clinical assistants] and providing to offer
and support by telephone to geographically distant clinics, rather
than giving on site support may have difficulties in defending
themselves or their staff in the event of a patient complaint.
Clinical assistants are becoming harder to appoint as staffing
salaries are so much below the level of remuneration that is possible
for doing GP sessions. Clinical Assistants may be prepared to
take posts in the short term to obtain experience but when this
is achieved to a basic level tend to move back to general practice
leaving the requirement of training (with the implications of
fewer patients being seen during this interval) the next clinicians.
Pressures of patient numbers and the need to see as many people
as possible lead to a reluctance to run training sessions for
GPs.
14.Patients' reluctance to complain in rural areas
because of associated stigma may give an inaccurate impression
of satisfaction with the service being tendered.
15.Single-handed practitioners providing 24 hour
support for HIV emergencies, inoculation injuries, and STD emergencies
cannot comply with the E U working times directives.
16.Implementation of consultant appraisal and five
yearly review will be difficult without reducing opportunity for
patient access to services unless funding levels increase.
17.From a low starting point in 1989 patient numbers
with HIV have increased 20 fold.
18.Support from consultant colleagues with an interest
in HIV medicine is reducing because of fears of medical litigation
and in response to GMC guidelines as the complexity of HIV management
increases.
19.Although access to HIV specialist care may be
available at geographically remote specialist centers, acutely
sick patients may be too ill to transfer. District hospital physicians
must be supported by their specialist colleagues.
20.Support and training for Single-handed to Genito
Urinary medicine definitions in rural areas is observed more in
theory than in practice as attendance at training meetings may
be impractical considering geographic distances to be covered.
Review of regional boundaries means that my regional teaching
centre (Manchester) now requires two hours of driving time in
each direction from one of my hospital clinics and three hours
each way from the other. Formerly, (Newcastle) an hour (or two)
in each direction was difficult but manageable. This makes a nonsense
of attending an hour's meeting if it requires six hours of travel.
21.Some targets of the National Sexual Health Strategy
may be achievable in some areas. New patient HIV screening may
be achievable, recent change to routine offering of HIV testing
to all new patients attending departments in North Cumbria has
lead to a huge increase in those (over 80%) who are tested but
this is a low prevalence area for HIV and the time implications
in this area are not too difficult to manage. Patients judged
to be at low risk of infection are invited to `phone for results.
(paper submitted to the BMJ). Targets for completed Hepatitis
B vaccination are unlikely to be achieved and may be more appropriate
for general practice because of the episodic access to care in
the former and continuing clinical responsibility in the latter.
22.Integration of family planning, general practice
and Genito Urinary medicine will compromise current levels of
patient confidentiality. The majority (approximately 85%) of patients
attending Departments of Genitourinary Infection in North Cumbria
attend without a GP referral.
23.Developments in clinical testing offer patient
advantages. (Chlamydia PCR testing.)
This technique which avoids having to obtain a urethral
scrape specimen from men has led to an increase in the willingness
for men to be screened. It is also a more sensitive test. Although
introduced only in November 2001, diagnoses of Chlamydia trachomatis
have doubled.
24.Recommendations
Increasing numbers of patients with increasingly
complex conditions should be appropriately funded.
Further increases in numbers should be matched with
finance.
Funding should be at an appropriate level to allow
development of nurse led clinics, access to an appointment within
one or two days, training, review audit appraisal etc.
Clarification and review of regional boundaries with
regard to referral patterns and commissioning responsibility is
urgent.
June 2002
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