Memorandum by Professor George Kinghorn
(HA 13)
GENITOURINARY MEDICINE SERVICES IN SHEFFIELD
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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