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Treating sexually transmitted infections in primary care: a missed opportunity?
  1. J A Cassell1,
  2. M G Brook1,2,
  3. C H Mercer1,
  4. S Murphy2,
  5. A M Johnson3
  1. 1Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, Off Capper Street, London WC1E 6AU, UK
  2. 2Patrick Clements Clinic, 2nd floor, West Wing Outpatients Department, Central Middlesex Hospital, North West London Hospitals NHS Trust, Acton Lane, London NW10 7NS, UK
  3. 3Centre for Infectious Disease Epidemiology, Department of Primary Care and Population Sciences and Department of Sexually Transmitted Diseases, University College London, UK
  1. Correspondence to:
 Dr Jackie Cassell;
 jackiec{at}quadrivium.demon.co.uk

Abstract

Objectives: To explore patterns of primary care attendance, barriers to the use of primary care, and views on services in a population of first time genitourinary medicine (GUM) clinic attenders.

Method: A cross sectional survey of new patients attending a mainly walk-in outer London GUM clinic, in which responses were linked to clinical data.

Results: 40.5% of all patients and 39.9% of those with an STI had already seen a GP for their current problem. This did not vary with age or symptom status. Duration of symptoms was highly significantly longer in patients who had attended a GP than in patients who attended a GUM clinic in the first instance. When patients who had not seen a GP were asked the reason for this, a third of responses cited the convenience of a GUM clinic or difficulty in accessing primary care services, while only 3% cited embarrassment and only 2% examination or gender issues.

Conclusion: Many patients initially attend GP services for STIs, and primary care is therefore already an important setting with potential for STI control. However, delay in treatment through attendance at primary care, and barriers in access to primary care, need to be addressed in the planning of future services.

  • sexually transmitted infections
  • primary care
  • access

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Most diagnosed cases of sexually transmitted infections (STIs) are thought to present to genitourinary medicine (GUM) clinics, and current surveillance data only reflect cases seen in a GUM clinic. The sexual health strategy1 proposes moving much care for STIs into primary care, yet there are few data on the feasibility or acceptability of this move. We studied patterns of primary care attendance and views on services among GUM attenders, so as to explore the current and potential role of primary care in STI care.

METHODS

We undertook a cross sectional survey of new patients attending a mainly walk-in, outer London GUM clinic in which 41.8% of patients were of Afro-Caribbean, 13.6% of Asian, and 9.4% of African origin. Respondents answered questions about how they had heard about the clinic; their main reason for attendance; whether they had already seen a general practitioner (GP) for the current problem; what they would do if they couldn’t be seen in a GUM clinic today, and their duration of symptoms. Responses were linked to a dataset extracted from the clinic database, which included patient characteristics and diagnostic codes. Patients who had not seen their GP were asked to provide a free text reason for this choice during the first half of the study only (for logistical reasons), and these were coded. Brent medical ethics committee approved the protocol. Quantitative data were analysed using stata version 7. After univariate analysis, a t test or the χ2 test for association was used to explore the relation between explanatory and dependent variables.

RESULTS

Of 1084 new patients, 752 (69.4%) completed a questionnaire, of which 721 (95.9%) could be linked to case notes and were used.

Some 40.5% of patients had already seen a GP for their current problem (table 1). This varied significantly by sex, but not by the presence or absence of an STI (defined as gonorrhoea, genital chlamydia, syphilis, non-specific urethritis, primary warts, or primary herpes). Among those with a diagnosed STI, 39.9% had already seen a GP. Patients who had seen their GP reported a longer duration of symptoms than those attending GUM directly.

Table 1

Patient characteristics, and associations with attendance at GP surgery (n=721)

In all, 36.9% of patients said that they found out about the GUM clinic from their GP or practice nurse, but only 17.5% of all patients would have seen a GP if the GUM clinic had not been able to fit them in that day.

Of those who had not seen their GP, 189 patients gave 211 free text reasons why not (fig 1). No patient gave more than two reasons. A third of reasons given were the greater speed or convenience of accessing a GUM clinic, or were non-registration with a GP. Embarrassment was rarely cited, while many patients viewed GUM services positively as more competent, or a source of specialist advice.

Figure 1

Reasons given for attending GUM clinics rather than primary care.

DISCUSSION

Four out of 10 patients attending GUM clinics have already seen a GP for their current problem. This is higher than previously shown,2 though consistent with data suggesting that patients are often informed about GUM services by informal or formal contact with primary care.3 Our data suggest that primary care may be able to manage more of these patients, if appropriate supporting services (such as specialist partner notification) are put in place.

Patients under 25 and patients with an STI were no less likely to attend primary care than other patients, suggesting that many higher risk patients do use their GP for sexual health, contrary to current opinion.4

Importantly, there is evidence that immediate treatment in primary care could enhance STI control, since duration of symptoms was significantly longer in patients who had already attended their GP.5 Our study is limited by the absence of patients who were treated entirely in the primary care setting, and as such will tend to over-represent problems in accessing primary care. Nevertheless, it does show that any move to increase STI treatment in primary care must cater for the large minority of patients who reported difficulty in accessing primary care.

While a third of the reasons cited for choosing GUM over primary care related to ease of access to a GUM clinic (in this predominantly walk-in service) or non-registration with primary care, it is of note that many of the reasons given by patients expressed positive judgments about GUM services, and the expertise they offer.

Acknowledgments

We are grateful to reception staff at the Patrick Clements Clinic for administering the questionnaire.

REFERENCES

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