Postgraduate training in genitourinary medicine, HIV in-patient care and the future role of the speciality
- Correspondence to Dr Rak Nandwani, Sandyford, NHS Greater Glasgow & Clyde, 6 Sandyford Place, Glasgow G3 7NB, UK;
How will doctors provide care for sexually transmitted infections (STIs) in the UK in future? Will they be hospital-based general physicians with a special interest in STIs participating in medical receiving or will they be in community settings overseeing multidisciplinary delivery of integrated sexual health? And what of HIV in-patient care? Will Genitourinary medicine (GUM) specialists continue to maintain responsibility for unwell patients? Or will GUM have disappeared having been absorbed into European Dermato-Venereology or dismantled by non-National Health Service care providers?
So far, GUM has an excellent record of keeping abreast with service redesign and external policy drivers. Postgraduate training is a key component of the specialty’s ability to do so. A major update of the GUM specialty training curriculum was published in 2010.1 This incorporated significant expansion of competencies in HIV medicine, reproductive health, public health and management/leadership.2 The GUM curriculum mirrors the current role of the specialty by ensuring that doctors gain all competencies required by existing health services. The curriculum also acts a portal to the future role of the specialty by equipping trainees with additional knowledge and skills which can be used to respond to new opportunities. To this end, recent amendments covering child/adolescent care and gender-based violence were added to the curriculum in 2012.1 The General Medical Council also issued a position statement requiring all trainees to transfer to the latest version of each curriculum by 2015 to safeguard patient safety and educational quality.3
The 2010 GUM curriculum incorporated the shift towards integrated sexual health and the impact of antiretroviral therapy on service provision, however since then, three other new drivers have emerged which are likely to have major implications. The first is the ‘Shape of Training’ review.4 There is already mounting pressure for core medical training to be lengthened to include more generic experience and to help cover acute receiving rotas. It has also been suggested that physicians in ‘acute bed-based specialties’ should continue to deliver General Medicine alongside their main specialty. The second driver is the requirement for more consistent hospital in-patient care5 including the presence of consultants 7 days a week.6 The third is the implementation of the Health and Social Care Act 2012 in England.7 This trinity of new initiatives has the potential to converge on the way that HIV in-patient care is provided. It has been recognised for some while that HIV services in London have been sub-optimally commissioned, and as one report phrased it: ‘‘Reviews’ are preferred to ‘action’’.8 A national HIV Commissioning Board may therefore consider concentrating specialist HIV in-patient services at a smaller number of units to provide sufficient critical mass for optimal care and to maintain staff competencies. The key question is whether GUM is well-placed to remain a major player providing care for HIV in-patients in future?
For many years, there has been implied or overt criticism that acutely unwell in-patients should not be cared for by GUM physicians because they do not participate in acute medical receiving. However the GUM curriculum supports development of all competencies required to potentially deliver both HIV in-patient and out-patient care. There is more detail provided on HIV than in any other curriculum,9 including for example, Infectious Diseases (for whom the passing the Diploma of HIV Medicine is recommended but not mandatory as it is for GUM trainees). The GUM Specialty Advisory Committee also recognises that relatively few trainees will be appointed to consultant posts where HIV in-patient duties account for the majority of their job plan and is considering whether pre- or post-CCT (Certificate of Completion of Training) Fellowships might be developed for additional competencies. However it is not clear what these are and there is an expectation that other specialties who provide HIV in-patient care would also need to demonstrate them. Existing GUM consultants who provide in-patient care deliver good practice by seeking input from other specialties and disciplines as required, working in regional networks with formalised protocols/care pathways and maintaining continuing professional development in both HIV and General Medicine by attending approved training courses as well as experientially. For some individuals, this experience extends to having seen large numbers of patients with advanced HIV/AIDS in the era before antiretrovirals. This approach is endorsed in current HIV standards of care.10 ,11
Given the immediate threats that GUM faces, it is understandably difficult to look ahead when the survival of the specialty is at stake. However, there is also a need to recognise that GUM must remain alert to wider developments that are already in progress and which may drastically alter the role of the speciality, particularly in relation to HIV in-patient care.
Competing interests RN is Chair of the Genitourinary Medicine Specialty Advisory Committee of the Joint Royal Colleges Postgraduate Training Board (JRCPTB) and a BASHH Board Member/Trustee. The views are expressed are his own and not necessarily those of JRCPTB or BASHH.
Provenance and peer review Not commissioned; externally peer reviewed.