STI services in the United Kingdom, how shall we cope?
http://www.100md.com
《性传输感染》
Keywords: STI services; United Kingdom
The recent proposals/debate addressing the increasing genitourinary medicine (GUM) workload1 are imaginative. I wish to contribute the following observations.
The listed "guiding principles" for the GUM services role are missing the most important function that is expected by patients: to exclude sexually transmitted infections. Casual sex, contact tracing, and sexual assault are examples of conditions that require full assessment.
The revelation that some 9% of the sexually active population are harbouring asymptomatic chlamydial2 infection presents GUM physicians with a professional responsibility. Chlamydia screening will require extensive resources from primary care.3
The debate ignores the issue of funding. To assume that GPs are going to provide "additional services" for a lower cost than GUM clinics, with their existing infrastructure, contradicts the basis of health care economics.4
The relation between quantity and quality of health care is inverse; with both healthcare workers and clients appreciative of this relation. The pressures for quantity will eventually force the quality of care downhill.5
Clinical governance implicates clinicians (as providers and stakeholders) in the quality of their provisions of services. It would be professionally unwise to compromise on quality as a result of the static, or a relative decrease in, funding. It is professionally unacceptable and could prove medicolegally indefensible.6
The open access of the GUM clinics will always attract patients, and the free prescriptions will continue to influence demand (particularly with recurrent infections).
There is a potential of primary care’s initial enthusiasm to fade away, with patients re-diverted to GUM clinics, while resources are tracking in the other direction.
The provisions of service should be based primarily on clinical needs, with a clearer understanding of the difference between screening and testing. The task of providing screening (for example, for chlamydia) in primary care (leading to the cascade of recall of positive cases, the treatment of patients’ conditions, and the referral for contact tracing) should be implemented fully in primary care, before any other directives.
Primary care units, providing full testing for STIs, should follow the same clinical governance and quality assurance standards expected and provided in GUM clinics. The issues of access, confidentiality, free prescriptions and reporting conditions (coding: KC60) have not been addressed yet in primary care settings.
I propose the following alternative models of service.
"Three tiered" GUM services are provided, within existing GUM departments, where care is streamlined with defined "clinical care pathways:"
The first tier/setting of service could be provided by nurses and/or junior doctors (under the supervision and support of senior GUM physicians). It will triage patients and deal with primary care conditions.
The secondary tier/setting would deal with clinical conditions of intermediate complexity (that prove to be outside the expertise of the first setting). It will be provided by medical staff, of intermediate seniority, supported by senior/specialised nurses.
The tertiary tier/setting is already existing within most GUM services (for example, HIV, sexual dysfunction, genital dermatosis, forensic genitourinary medicine). It will be provided by specialised medical staff, assisted by specialised nurses, where junior grades attend for training.
A "three sessions" day could be provided, to maximise the use of accommodation and infrastructure resources. Evening and/or weekend clinics to be considered—with appropriate funding.
The provision of satellite GUM clinics where local services are unable to cope with demands. They could be provided (and supported) by existing larger primary care, GPs and/or family planning units, under the auspices of the main GUM clinic. This will maintain and ensure quality, KC60 reporting, confidentiality, and/or free prescribing.
These modules are already taking shape in some GUM departments.
References
Bradbeer C, Mears A. STI services in the United Kingdom, how shall we cope? Sex Transm Infect 2003;79:435–8.
Underhill G, Hewitt G, McLean L, et al. Who has chlamydia? The prevalence of genital tract chlamydia trachomatis within Portsmouth and South East Hampshire, UK. Fam Plann Reprod Health Care 2003;29:17–20.
Pimenta JM, Catchpole M, Rogers PA, et al. Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases. Sex Transm Infect 2003;79:22–7.
World Health Organization. European observatory on healthcare systems: financial resource allocation, in healthcare systems in transition: United Kingdom. Copenhagen: WHO Publications, 1999.
Saltman RB, Figueras J. Confronting resource scarcity. In: European healthcare reform. Copenhagen: WHO Publications, 1997.
Ferguson AL. Legal implications of clinical governance. In: Lugon M, Secker-Walker J, eds. Clinical governance. London: Royal Society of Medicine Press, 2001.(A R Markos)
The recent proposals/debate addressing the increasing genitourinary medicine (GUM) workload1 are imaginative. I wish to contribute the following observations.
The listed "guiding principles" for the GUM services role are missing the most important function that is expected by patients: to exclude sexually transmitted infections. Casual sex, contact tracing, and sexual assault are examples of conditions that require full assessment.
The revelation that some 9% of the sexually active population are harbouring asymptomatic chlamydial2 infection presents GUM physicians with a professional responsibility. Chlamydia screening will require extensive resources from primary care.3
The debate ignores the issue of funding. To assume that GPs are going to provide "additional services" for a lower cost than GUM clinics, with their existing infrastructure, contradicts the basis of health care economics.4
The relation between quantity and quality of health care is inverse; with both healthcare workers and clients appreciative of this relation. The pressures for quantity will eventually force the quality of care downhill.5
Clinical governance implicates clinicians (as providers and stakeholders) in the quality of their provisions of services. It would be professionally unwise to compromise on quality as a result of the static, or a relative decrease in, funding. It is professionally unacceptable and could prove medicolegally indefensible.6
The open access of the GUM clinics will always attract patients, and the free prescriptions will continue to influence demand (particularly with recurrent infections).
There is a potential of primary care’s initial enthusiasm to fade away, with patients re-diverted to GUM clinics, while resources are tracking in the other direction.
The provisions of service should be based primarily on clinical needs, with a clearer understanding of the difference between screening and testing. The task of providing screening (for example, for chlamydia) in primary care (leading to the cascade of recall of positive cases, the treatment of patients’ conditions, and the referral for contact tracing) should be implemented fully in primary care, before any other directives.
Primary care units, providing full testing for STIs, should follow the same clinical governance and quality assurance standards expected and provided in GUM clinics. The issues of access, confidentiality, free prescriptions and reporting conditions (coding: KC60) have not been addressed yet in primary care settings.
I propose the following alternative models of service.
"Three tiered" GUM services are provided, within existing GUM departments, where care is streamlined with defined "clinical care pathways:"
The first tier/setting of service could be provided by nurses and/or junior doctors (under the supervision and support of senior GUM physicians). It will triage patients and deal with primary care conditions.
The secondary tier/setting would deal with clinical conditions of intermediate complexity (that prove to be outside the expertise of the first setting). It will be provided by medical staff, of intermediate seniority, supported by senior/specialised nurses.
The tertiary tier/setting is already existing within most GUM services (for example, HIV, sexual dysfunction, genital dermatosis, forensic genitourinary medicine). It will be provided by specialised medical staff, assisted by specialised nurses, where junior grades attend for training.
A "three sessions" day could be provided, to maximise the use of accommodation and infrastructure resources. Evening and/or weekend clinics to be considered—with appropriate funding.
The provision of satellite GUM clinics where local services are unable to cope with demands. They could be provided (and supported) by existing larger primary care, GPs and/or family planning units, under the auspices of the main GUM clinic. This will maintain and ensure quality, KC60 reporting, confidentiality, and/or free prescribing.
These modules are already taking shape in some GUM departments.
References
Bradbeer C, Mears A. STI services in the United Kingdom, how shall we cope? Sex Transm Infect 2003;79:435–8.
Underhill G, Hewitt G, McLean L, et al. Who has chlamydia? The prevalence of genital tract chlamydia trachomatis within Portsmouth and South East Hampshire, UK. Fam Plann Reprod Health Care 2003;29:17–20.
Pimenta JM, Catchpole M, Rogers PA, et al. Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases. Sex Transm Infect 2003;79:22–7.
World Health Organization. European observatory on healthcare systems: financial resource allocation, in healthcare systems in transition: United Kingdom. Copenhagen: WHO Publications, 1999.
Saltman RB, Figueras J. Confronting resource scarcity. In: European healthcare reform. Copenhagen: WHO Publications, 1997.
Ferguson AL. Legal implications of clinical governance. In: Lugon M, Secker-Walker J, eds. Clinical governance. London: Royal Society of Medicine Press, 2001.(A R Markos)