Select Committee on Health Minutes of Evidence

Memorandum by Professor George Kinghorn (HA 13)


1.  Sexual Health services in Sheffield have been served by a multidisciplinary Joint Planning Group (JPG) for several years. The JPG contains three members of the Sexual Health and HIV Independent Advisory Group. The local population, which exceeds 500,000, is culturally diverse with varying social need. It is boosted by a student population of 60,000, and is also a centre for asylum seekers especially for the relocation of families affected by HIV.

  2.   The Genitourinary Medicine (GUM) clinic, which is based in the acute Trust, is one of the busiest in the country and has achieved a high reputation for clinical care, teaching, and research. It is open on six days each week and there is a "24-7" on-call team for inpatients and emergencies. Shared consultant posts with all surrounding clinics in District General Hospitals in South Yorkshire and North Trent have allowed the development of an effective clinical network.

  3.  Patient demand has rapidly increased during the past decade. Between 1996-2001, the annual numbers of new patients attending the clinic increased by 13%. Since 2001, there have been accelerated pressures on the clinic service. For the period 2001-03, the recorded increases for annual total caseload was 73%, for new patient episodes was 30%. The annual number of gonorrhoea cases has doubled and of new HIV patients has trebled. Moreover, syphilis, previously seen only sporadically, has re-emerged as an increasingly common infection.

  4.  The service has responded to this increasing demand by extensive modernisation of clinical practice by means of additional clinic sessions, developing nurse practitioner posts, reducing patient follow-up attendances, updating clinical management strategies, and revised triage systems, all designed to increase service capacity.

  5.  It has introduced several innovations. These include a new consultant post shared between GU Medicine and specialist Contraception Services, to coordinate the community-based chlamydia screening programme that began in 2004; all chlamydia tests from all clinical sites in the city are now tested using the most sensitive nucleic acid amplification (NAAT) methods. A new nurse consultant post in health advising has been established to develop partner notification for STIs in community settings, and a new specialist HIV social worker is employed to cater for the complex problems of HIV-affected black and ethnic minorities. We were also amongst the first GUM centres in the UK to streamline HIV testing and the annual numbers of patients accepting testing in our clinic doubled to 8,500 during 2001-03.

  6.  Despite all of these changes, there has been a serious deterioration in GUM access times. HPA data for May 2004 shows that the numbers of patients who were able to access the clinic within 48 hours of first contact was only 20%. The average time to a routine appointment has increased to around three weeks. The current waiting list now exceeds 600 individuals and continues to grow week by week. Despite our triage system, which aims to give priority to the symptomatic individuals and the young, gonorrhoea and chlamydia rates continue to increase, as do new cases of HIV, not least in pregnant women, and the re-emergence of syphilis cases in the city is very worrying.

  7.  GUM clinics were notified by the Department of Health of non-recurrent allocations of additional funding beginning in 2003 to promote additional capacity. Only half of the initial £140,000 allocation designated for GUM was received.[1] The remainder was retained by the PCT for other purposes not related to sexual health. This failure to receive the total funding, which was justified by the PCT on the basis that GUM services were not a national or local priority, significantly impaired confidence and our ability to expand service capacity in a timely fashion.

  8.  Fortunately, since the additional targeted GUM funding has been made recurrent, the PCT has agreed to transfer the full amount of the additional allocation for GUM during the current year. As the clinic is now located within a Foundation Trust (FT), we attract full tariff for overperformance against the baselines agreed in the service level agreement. This contrasts with the non-FT GUM clinics, which only receive marginal costs for additional workload that do not cover the step costs of delivering more patient service.

  9.  Any further expansion of workload in severely impaired by serious space constraints. Our dedicated clinic premises were designed 25 years ago for less than half the current workload. In order to increase patient throughput, we have a very urgent need for additional consulting rooms and appropriate accommodation for personnel. The department was selected as the Strategic Health Authority choice for a share of the designated £15 million capital funding for GUM infrastructure. This funding was inadequate and was eventually allocated only to those services currently in temporary accommodation eg portacabins. Whilst this is understandable, this leaves significant accommodation/capacity issues that are pressing in Sheffield and elsewhere, which require a substantial increase in targeted capital allocations.

  10.  Up until 2004, there has been relatively little STI care delivered within community settings. The vast majority of patients with suspected or diagnosed STIs that initially present at other settings are referred to the specialist service for further patient and partner management and follow-up.

  11.  We have long been involved in undergraduate teaching and providing full-time and flexible specialist training. We are also committed to assisting the development of plurality of service provision within the city, and to actively support new community-based services for STI care. To achieve this end, we have already successfully introduced STI Foundation courses aimed at primary care doctors and nurses. But this theoretical training needs to be supplemented by increased opportunities for practical training and competency assessment within the clinic. Unless there are more staff and more space, it will not be possible to increase this to meet local requirements.

  12.  We are very pleased that many of the recommendations contained within the Health Select Committee report have now been adopted by the government in "Choosing Health- making healthy choices easier", not least the additional priority at both national and local level that has been given to Sexual Health, and the strong performance management advocated to make progress to the 48-hour maximum wait goal for 2008. However, even in Sheffield where there is a strong tradition of innovation, of co-operative working between different sexual health services, and of extensive sexual health education, the situation is rapidly deteriorating. There is real concern that a new national education campaign will be undertaken before there has been satisfactory planning of the service consequences of this further stimulus to patient demand.

  13.  We strongly recommend that services for sexually transmitted infections and HIV receive immediate support. We need to plan for a 30-50% increase in GUM patient throughput before 2008, and to provide practical training of dozens of primary care practitioners to provide a similar or greater increase in capacity at community settings. To achieve the latter objective, we recommend that a sexual health-training budget be established.

  14.  Expansion of the numbers of clinical personnel and of clinic space to accommodate training needs should begin immediately if we are to achieve the 2008 goal. In our view, the longer the delay before the new resources filter down to clinic level, the greater the risk of deepening the current sexual health crisis and of more preventable damage to the nation's Public Health.

December 2004

1   Kinghorn GR, Abbott M, Ahmed-Jushuf I, Robinson AJ "BASHH survey of additional Genitourinary Medicine targeted allocations in 2003 and 2004". International Journal of STIs&AIDS 2004; 15; 650-62. Back

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