Building the bypass—implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009
- Catherine H Mercer1,
- Catherine R H Aicken1,
- Claudia S Estcourt2,3,
- Frances Keane4,
- Gary Brook5,
- Greta Rait6,
- Peter J White7,8,
- Jackie A Cassell1,9
- 1Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London, Mortimer Market Centre, London, UK
- 2Centre for Infectious Disease: Sexual Health and HIV, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, Barts Sexual Health Centre, St Bartholomew's Hospital, London, UK
- 3Infection and Immunity, Barts and the London NHS Trust, London, UK
- 4Department of Genito-urinary Medicine, Royal Cornwall Hospitals NHS Trust, The Hub, Royal Cornwall Hospital (Treliske), Truro, Cornwall, UK
- 5Patrick Clements Clinic, Central Middlesex Hospital, North West London Hospitals NHS Trust, London, UK
- 6Research Department of Primary Care and Population Health, University College London, London, UK
- 7MRC Centre for Outbreak Analysis & Modelling, Department of Infectious Disease Epidemiology, Imperial College Faculty of Medicine, London, UK
- 8Modelling & Economics Unit, Health Protection Agency Centre for Infections, London, UK
- 9Brighton and Sussex Medical School, Mayfield House, University of Sussex, Falmer, Brighton, UK
- Correspondence to Dr Catherine H Mercer, Centre for Sexual Health and HIV Research, 3rd floor Mortimer Market Centre, off Capper Street, London WC1E 6JB, UK;
Contributors CHM had the original idea for the paper and obtained funding for the MSTIC study with JAC, who also obtained funding and had the original idea for the PATSI study. The questionnaire for the MSTIC study was jointly developed by all authors, led by CRHA who also piloted the questionnaire. Plans for analysis were led by CHM, who undertook all data management and statistical work. CHM wrote the first draft of the paper, which was revised with contributions from all authors. CHM is guarantor.
- Accepted 18 November 2011
- Published Online First 23 December 2011
Objective The objective of this study was to examine changes in patient routes into genitourinary medicine (GUM) clinics since policy changes in England sought to improve access to sexual healthcare.
Methods Cross-sectional patient surveys at contrasting GUM clinics in England in 2004/2005 (seven clinics, 4600 patients) and 2009 (four clinics, 1504 patients). Patients completed a short pen-and-paper questionnaire that was then linked to an extract of their clinical data.
Results Symptoms remained the most common reason patients cited for attending GUM (46% in both surveys), yet the proportion of patients having sexually transmitted infection (STI) diagnosis/es declined between 2004/2005 and 2009: 38%–29% of men and 28%–17% of women. Patients in 2009 waited less time before seeking care: median 7 days (2004/2005) versus 3 days (2009), in line with shorter GUM waiting times (median 7 vs 0 days, respectively). Fewer GUM patients in 2009 first sought care elsewhere (23% vs 39% in 2004/2005), largely from general practice, extending their time to attending GUM by a median of 2 days in 2009 (vs 5 days in 2004/2005). Patients with symptoms in 2009 were less likely than patients in 2004/2005 to report sex since recognising a need to seek care, but this was still reported by 25% of men and 38% of women (vs 44% and 58%, respectively, in 2004/2005).
Conclusions Patient routes to GUM shortened between 2004/2005 and 2009. While GUM patients in 2009 were less likely overall to have STIs diagnosed, perhaps reflecting lower risk behaviour, there remains a substantial proportion of high-risk individuals requiring comprehensive care. Behavioural surveillance across all STI services is therefore essential to monitor and maximise their public health impact.
- Genitourinary medicine services
- primary care
- general practice
- service delivery
- sexual behaviour
- sexual practices
- risk behaviours
- sexual health
- sexual networks
- public health
- GUM services
- service development
- risk profiles
- STD clinic
- information technology
- primary care
There have been huge changes in the delivery of sexual healthcare in England over the past decade reflecting recent national guidance1 2 and targets,3 which stressed the importance of improving access to sexual healthcare. Waiting times to access genitourinary medicine (GUM) clinics have reduced considerably with 99% of patients now offered an appointment within 48 h of contacting GUM.3 The role of primary care in the diagnosis and treatment of sexually transmitted infections (STIs) has expanded,1 resulting in a significant increase in the number and proportion of STIs diagnosed in general practice4–6 and in less specialised community settings more generally, including through the National Chlamydia Screening Programme.7 However, there is evidence that STIs are sometimes inappropriately managed in these settings,8–11 and provider-led partner notification is rarely available in primary care. This has public health implications since patients with acute STIs who are not appropriately managed are at risk of clinical complications and prolonged periods of infectivity, thus increasing the likelihood of transmission. As less specialised community services expand, understanding their interaction with patients' routes to GUM is crucial for informing the future role of GUM clinics in the provision of STI care and transmission prevention in England. This paper seeks to gain this understanding by examining changes in patient routes into GUM between 2004/2005 and 2009.
We compared data from two cross-sectional surveys of people attending GUM clinics in sociodemographically and geographically contrasting areas in England, conducted in 2004/2005 and 2009. In 2009, we developed a patient questionnaire as part of the Maximising STI Control in local populations study.12 This questionnaire was based on one developed for the earlier Patient Access and the Transmission of Sexually-transmitted Infections study carried out in 2004/2005,13 which provides comparator data. While these short pen-and-paper questionnaires differed slightly, reflecting the different objectives of the two studies, many key questions were identical, permitting comparative analyses. Questions included reason(s) for attending GUM, presence and duration of symptoms, routes into GUM and recent sexual behaviour. Both questionnaires are available online.12 13
Four GUM clinics in England were purposively recruited: a London clinic serving a large commuter population, a London clinic serving an ethnically diverse population, a suburban clinic serving an ethnically diverse population and a clinic serving a semirural population. Clinic reception staff distributed questionnaires to all patients over a period of 3–8 weeks between August and December 2009, depending on clinic size, with larger clinics having shorter data collection periods. Questionnaires were anonymous apart from the patient's clinical identification number written on the front of the questionnaire by reception staff, together with the date of attendance. In the questionnaire, respondents were asked to indicate consent to linkage of their questionnaire data to routinely collected clinical data to obtain data on STI diagnosis/es made during their episode of care.
Seven GUM clinics across England were purposively recruited, which included clinics in large provincial cities, a suburban clinic serving an ethnically diverse population, a clinic serving a substantial Asian population and clinics serving semirural populations. Between October 2004 and May 2005, reception staff distributed questionnaires to patients attending for a new episode of care, with the data collection period again proportional to the size of the clinic. Questionnaire data were linked to clinical data as in the 2009 survey. Two of these seven clinics also participated in the 2009 study (the suburban clinic serving an ethnically diverse population and one of the semirural clinics).
The denominator for the 2009 sample was limited to new patients and patients attending for a new episode of care for consistency with the 2004/2005 study. Samples were stratified by gender and compared in terms of key sociodemographic and health factors using the χ2 statistic. We also used logistic regression to obtain crude ORs and ORs adjusting for differences in sample characteristics to compare the 2009 data to the 2004/2005 data, the latter acting as the reference category. Statistical significance was considered as p<0.05 for all analyses. Analyses were undertaken using the survey commands in Stata V.10.014 to take account of clustering of patients by clinic.
The research protocol for the 2009 study was approved by the London Research Ethics Committee (number: 09/H0718/1), while ethical approval for the 2004/2005 study was obtained from the South West Multi-Centre Ethics Committee (number: MREC/04/6/02).
Response rates in both studies varied by clinic, ranging 17.8%–70.1% in 2004/2005 and 24.9%–76.1% in 2009. In 2009, 76.0% of respondents consented to data linkage between their questionnaire and clinical data, while 86.4% of patient questionnaires were linked in 2004/2005. No significant differences were observed with respect to key variables in the questionnaire between patients with and without clinical data in either survey.
Aggregate routinely collected data on gender, age, ethnicity and STI diagnoses were used to compare those who completed the questionnaire with the clinic population. Respondents in 2009 were found to be slightly younger on average than patients in the clinic population (40.8% vs 35.4%, respectively, were younger than 25 years). A similar comparison within the 2004/2005 data did not find any differences.13
There were no differences between the 2004/2005 and 2009 samples in their gender, age or ethnic composition (table 1). Men were older than women by 3 years on average in both samples. Over 70% of all patients were recorded as being of white ethnicity. An overwhelming majority of patients were registered with a general practice with no difference between the two studies. While patients in 2009 were more likely to report previous STI diagnosis/es than patients in 2004/2005 (39.7% vs 17.0%, no difference by gender), they were less likely to have at least one acute STI diagnosed at, or following, their GUM clinic visit, in 2009 versus 2004/2005, respectively: 29.0% versus 38.2% (men); 16.7% versus 28.1% (women). These patterns remained when the samples were limited to the two clinics that participated in both studies (web table 1).
Reason for attending GUM
The reasons cited for clinic attendance did not change between 2004/2005 and 2009 (figure 1). The three most commonly cited reasons were, first, having (had) symptoms; second, not having symptoms but wanting a check-up; and third, wanting an HIV test. There were no significant differences in the magnitude of these proportions by study or gender.
A larger proportion of men in 2009 than in 2004/2005 reported attending GUM because their partner had (had) symptoms: 12.7% versus 9.8%, respectively (p=0.018). However, this trend was reversed among women: 7.3% versus 11.6%, respectively (p=0.027). In 2009, 5.2% of patients reported attending GUM because their partner had been diagnosed with an infection and they recognised a need to seek care themselves, which was smaller than in 2004/2005 (10.6%, p<0.001). In addition, while attending the clinic as a result of provider-led partner notification was seldom reported in either study, fewer patients reported this in 2009 than in 2004/2005: 0.2% versus 2.2%, respectively (p=0.001). Adjusting for the sample characteristics shown in table 1 via multivariable analyses did not change these findings (web table 2).
A smaller proportion of patients reporting symptoms as their reason for attendance had acute STI diagnosis/es in 2009 than in 2004/2005, particularly among women: 22.5% versus 36.2%, respectively (among men: 42.9% vs 50.5%, respectively; table 2). The proportion with acute STI diagnosis/es was also smaller in 2009 than in 2004/2005 among those reporting attending for an asymptomatic check-up: 14.7% versus 22.8% among men and 10.3% versus 16.6% among women.
Accessing care at the GUM clinics
Among patients reporting symptoms at their GUM clinic visit, the median waiting time between recognising a need to seek care and first trying to do so declined from 7 days in 2004/2005 to 3 days in 2009 (upper quartiles of 17 and 5 days, respectively). Once patients sought care, they received care more promptly in 2009 than in 2004/2005, with 61.9% of patients in 2009 reporting being seen at the study GUM clinic the same day that they first sought care in comparison to 21.3% of patients in 2004/2005 (corresponding medians (upper quartiles), 0 (2.5) days and 7 (16) days, respectively).
Seeking care from other healthcare providers prior to going to GUM
In 2009, 22.8% of GUM patients reported having used, or tried to use, another healthcare service for treatment or advice prior to going the study clinic, which was smaller than observed in 2004/2005 (38.6%, p<0.001, no gender difference in either study). In 2009, patients who reported having sought care elsewhere took a median of 2 days longer to get to the study clinic than patients who went straight to clinic. This compares to an average extended care pathway of 5 days among such patients in 2004/2005.
GUM clinic patients' experience of seeking care from general practice
In both studies, patients who reported seeking care elsewhere prior to going to the study clinic were most likely to cite doing so from general practice. However, this proportion declined from 73.5% in 2004/2005 to 58.7% in 2009 (p=0.007, table 3). A smaller proportion of GUM patients reported attending general practice in person in 2009 than in 2004/2005 (63.2% vs 80.5%, respectively, p=0.001). Among patients who attended the general practice, fewer reported seeing a healthcare professional or receiving treatment in 2009 than in 2004/2005 (82.8% vs 98.0% and 32.0% vs 66.7%, respectively). Meanwhile, the proportion reporting that someone in general practice had advised them to attend GUM increased between 2004/2005 and 2009 (table 3). These patterns remained when the samples were limited to the two clinics that participated in both studies (web table 3).
There was no change between 2004/2005 and 2009 in the proportion of GUM clinic patients who reported seeing healthcare professional(s) in general practice and who were then diagnosed with acute STI(s) in GUM: 40.3% (n=366) and 35.4% (n=34), respectively. Furthermore, while 102 of the 366 patients (27.9%) in 2004/2005 were then diagnosed in GUM with chlamydia, only one of the 34 patients (2.9%) was in 2009.
Sex since recognising a need to seek care
Reporting sex between recognising a need to seek care and attending the GUM clinic declined between 2004/2005 and 2009 from 43.6% to 25.2% among men (p=0.001) and from 57.7% to 38.3% among women (p=0.003). After adjusting for the number of days since patients first recognised a need to seek care, patients in 2009 were still less likely to report having had sex during this time than patients in 2004/2005: adjusted ORs 0.52 (95% CI 0.30 to 0.91, p=0.025) for men and 0.37 (95% CI 0.19 to 0.72, p=0.007) for women.
Most patients in 2009 who reported sex while needing care reported just one partner during this time: 76.9% of men and 87.6% of women. Of these patients, 43.9% reported new partner(s) during this time (no difference by gender; comparable 2004/2005 data are not available).
In 2009, patients reporting having sex since recognising a need to seek care reported a median of three sex-acts during this time (lower and upper quartiles: two and eight), reported having unprotected sex at least once during this time in three-quarters of cases (76.6%, no difference by gender) and were as likely to have acute STIs diagnosed as patients who abstained during this time (p=0.622 among men; p=0.200 among women; figure 2).
Statement of principal findings
Patient routes to the GUM clinics studied shortened considerably between 2004/2005 and 2009 due to patients both reporting seeking and receiving care more quickly. The decrease in the proportion of patients reporting sex since recognising a need to seek care may be a consequence of their shorter pathways. However, one-quarter of the men and more than one-third of the women studied in 2009 still reported sex during this time, risking onward transmission. Nevertheless, we observed a decline between 2004/2005 and 2009 in the proportion of the patients studied who had acute STI(s) diagnosed during their episode of care at GUM, despite no change in the reasons these patients reported for seeking care or in the proportion reporting symptoms.
Relation to wider literature
Our finding of an increase in the proportion of patients seen in GUM within 2 days of first seeking care is consistent with Genitourinary Medicine Monthly Access Monitoring (GUMAMM) data;3 however, our data provide greater detail regarding the indirect routes some patients take to reach GUM. Of note, our data show that GUM patients now seek care much sooner after recognising a need to do so and are less likely to report seeking care elsewhere prior to attending GUM. These findings are likely to reflect easier access to GUM in 2009 and are consistent with an increase in the proportion of all GUM patients who are new or presenting with a new problem,3 compared to the early/mid-2000s.15 Improved access to GUM is due to service modernisation but may also be due to an increased awareness of sexual health due to greater provision of STI testing in a diverse range of settings, including through the National Chlamydia Screening Programme. These factors have facilitated a greater number of people testing for STIs such that STI control appears to be succeeding according to recent surveillance data,16 as well as our finding that GUM clinic patients were less likely to have STI(s) diagnosed than in 2004/2005.
Strengths and weaknesses of the study
While we have relatively large samples of patients recruited from contrasting GUM clinics across England, capturing different types of population, we used convenience sampling so we cannot consider our data as fully representative of the GUM clinic population. While we observed only one statistically significant difference between our sample and the participating clinics' patient populations (40.8% vs 35.4%, respectively, were younger than 25 years), routinely collected data were not available for many patient characteristics so the number of such comparisons we could make was limited. In particular, we were not able to compare sexual risk behaviours among the GUM clinic population for either time point or to consider how these risk behaviours may have changed over time. Regrettably this included whether male patients had sex with men, who differ from men who only have sex with women, for example, in terms of their presence of symptoms, and reason(s) for attendance. Potential differences in the proportion of male patients who had sex with men in the two samples need to be borne in mind when interpreting our findings.
While we did not observe any sociodemographic differences in sample composition in 2009 versus 2004/2005, there was an increase in the proportion who reported previous STI diagnosis/es but a decrease in the proportion who were diagnosed with acute STIs during their episode of care. Although these patterns were also observed when we limited the denominator to the two clinics that participated in both studies, we acknowledge that some of the difference in the outcomes studied may be in part due to differences in the participating clinics at each time point—a limitation of using convenience sampling.
We also acknowledge the substantial variation in the response rate at the different clinics, which we attribute, in part, to reception staff not offering questionnaires to all patients, reflecting how enthusiasm for the research varied between reception staff teams, and in some services, short-staffing.
Meaning of the study: possible mechanisms and implications for clinicians or policymakers
Access to sexual healthcare has certainly improved over the 5 years studied, but there remain some challenges. While symptoms remain the most commonly cited reason for seeking care, a substantial minority who did not report symptoms as a reason for seeking care had acute STI(s) diagnosed in 2009 (one in six men and one in 10 women). Risk assessment and triage strategies that seek to differentiate patients according to the presence/absence of reported symptoms are therefore inappropriate and ill-advised.17
The delay to patient routes into GUM among those first seeking care from non-GUM settings reduced between 2004/2005 and 2009. This may suggest increases in formal referral to GUM as there is evidence that GUM patients who had previously presented at general practice were seen quicker in GUM if they received a written referral from a general/nurse practitioner.18 However, although we observed an increase in the proportion of patients reporting that they had been advised to attend GUM when they had sought care from general practice, we did not ask about the nature of referral, and other studies suggest a continued absence of formal supported referral from community-based services to GUM.18–20 Initiatives that facilitate rapid referral to GUM are therefore imperative.
In line with recommendations that chlamydia could, and should, be managed in any healthcare setting,1 the proportion of patients diagnosed with chlamydia in GUM who had already seen a healthcare professional in general practice reduced considerably between 2004/2005 and 2009, suggesting a reduction in workload duplication. However, we acknowledge that our sample of patients who sought care from general practice for suspected STIs is limited as it excludes those managed solely in general practice and those referred who did not attend GUM. However, these are likely to be the exception, not the rule, other than chlamydia cases.8–11
It is likely that shorter patient routes to GUM have resulted in fewer people having sex after recognising a need to seek care. However, multivariable analyses adjusting for the time patients took to get to GUM did not account for the decline between 2004/2005 and 2009 in this proportion, suggesting changes in behaviour over time, yet a substantial minority of patients reported continuing sexual activity. Health promotion needs to continue to encourage patients to seek care as soon as they recognise a need to do so and to abstain from sex during this time.
Women continue to be more likely than men to report sex since recognising a need to seek care. This may reflect differences in the types of partnerships men and women have and/or gender power inequalities, possibly linked to the tendency for women to be younger than their male sexual partners.21 Strategies that empower women and enable them to communicate effectively with their partners may help women abstain from sex when they suspect they have an STI. The increase between 2004/2005 and 2009 in the proportion of men reporting attending GUM because their partner had symptoms may be an indication that such communication is improving.
Unanswered questions and future research
While GUM clinic patients may now be less likely to be diagnosed with STIs, it cannot be assumed that all management can be provided by community settings, especially as many of these are only able to offer basic testing for STIs. Failing to meet the more complex needs of some patients if they do not have access to specialist STI services has an inevitable public health consequence of increased STI transmission. There is a need for behavioural surveillance across all sexual healthcare settings in order to understand the varying risk profiles of patients and to ensure that the highest risk individuals can access care from providers that can offer the full range of services.
Time to seeking care and to accessing GUM care reduced between 2004/2005 and 2009 among the patients studied, with less duplication through prior attendance in general practice.
The proportion of patients studied who reported having sex after recognising a need to seek care reduced and was not fully accounted for by reduced waiting times.
GUM patients may still include a substantial number of people with high-risk behaviour including multiple partnerships around the time of attendance.
Ensuring the public health benefits of STI services requires surveillance of their ability to attract the highest risk individuals for comprehensive care and case finding through partner notification for those infected.
We are extremely grateful to all staff and patients at the participating clinics who contributed so much to the PATSI and MSTIC studies.
Funding The 2004/2005 study (full title: ‘Effects of Delayed Access to Services, Variation in Service Provision, and Lack of Partner Notification Services on the Transmission of STIs: Quantification of Impact in the UK’, abbreviated to ‘Patient Access and the Transmission of Sexually-transmitted Infections’ (‘PATSI study’)) was funded by the UK Medical Research Council, with funding allocated from the Health Departments, under the aegis of the MRC/UK Health Departments Sexual Health and HIV Research Strategy Committee (grant number G0200565). The 2009 study (full title: ‘Public Health Outcomes, Costs and Cost-effectiveness of GUM and Primary Care Based STI Services: How to Maximise STI Control and Cost-effectiveness for a Population’, abbreviated to ‘Maximising STI Control’ in local patients (‘MSTIC study’)) was funded by the UK Medical Research Council via the MRC/DH Sexual Health and HIV Research Strategy Committee (grant number G0601685). The funding bodies had no role in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The views expressed are those of the authors and not necessarily those of the MRC or the Health Departments.
Competing interests None.
Ethics approval The research protocol for the 2009 study was approved by the London Research Ethics Committee (number: 09/H0718/1), while ethical approval for the 2004/2005 study was obtained from the South West Multi-Centre Ethics Committee (number: MREC/04/6/02).
Provenance and peer review Not commissioned; externally peer reviewed.