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The public health control of sexually transmitted infections (STIs) demands open and immediate access for individuals with symptoms or other reasons to suspect they may be infected. The paper by Foley et al in this issue of STI (p 12) suggests that almost one quarter of clinics contacted by individuals with symptoms suggestive of acute STI were not offered appointments to be seen within the next 48 hours. Yet there was virtual unanimity among consultants responsible for clinics participating in the study that there were arrangements for such patients to be seen urgently.
Moreover, a subsequent survey collaboratively organised by the Communicable Diseases Surveillance Centre, AGUM, and the MSSVD,1 has also shown disturbing inequities in the accessibility of GUM clinic services, and suggested that such difficulties are becoming increasingly widespread throughout the United Kingdom.
The “patients” employed in the study by Foley et al had skills in the use of the telephone, were articulate and able to describe classic symptoms of acute STIs, and were insistent about the need to be seen urgently. It seems likely that those with lesser communication skills would have been less successful. This suggests the inequity in access is possibly increased for those with the greatest needs, such as the young, ethnic minorities, and other socially disadvantaged individuals.
GUM clinics have long attempted to counter stigma and improve both the acceptability and accessibility of their services. Their success has been demonstrated by the increasing annual new patient attendances of the past decade, the choice of a majority of HIV infected people in the United Kingdom to have their continuing care provided within GUM clinics, and the development of subspecialty interests for many chronic genitourinary conditions that are not sexually acquired. These chronic conditions often require time consuming consultations, however, the rapid consultant expansion between 1988 and 1997 has previously allowed the supply of clinician time to keep pace with increasing demand.
More recently, there appears to have been a further upsurge in demand while clinical expansion has stalled. The reasons for this increased demand are undoubtedly complex and incompletely understood. Many clinicians think that the success of HAART, and the subsequent declining incidence and mortality from AIDS, has relaxed adherence to safer sexual practices among a wide cross section of the community. Moreover, in the major cities, GUM resources have often been diverted to fund the rapidly escalating costs of antiretroviral treatment. Within the tight financial straitjacket imposed by trusts, the specialty has faced a growing HIV patient population and a rising tide of acute STI with static or reduced resources devoted to general GUM services.
In those clinics where Foley's patients could not access care within 48 hours, reception staff alone invariably performed triage. This is unacceptable. GUM clerical staff are often unsung heroes who provide a welcoming and supportive environment for apprehensive and frightened patients. However, they do not have the necessary clinical training to differentiate between acute and non-acute conditions and should never be expected to do so.
It is vital that the specialty reinforces its process standards. Only suitably trained, qualified clinical staff should perform triage. There should be written protocols within each clinic to provide clear guidance. Protocols should also include advice as to how patients can access appropriate health care for the treatment relief of acute symptoms when there is no immediate clinic session. This may require collaborative arrangements to be made with local accident and emergency services or other walk-in services. Adjacent clinics within a geographical locality should also consider joint arrangements to ensure that at least one GUM clinic can always provide urgent clinic access to patients within a reasonable travelling distance.
Written process standards together with collaboration and cooperation within clinical networks may help ameliorate access inequities. However, they will not address the fundamental imbalance between demands for GUM services and current resources. Concerted attempts through all of our national representative bodies must intensify and should complement local action to ensure that clinic resources are commensurate with the demands being placed upon the service. The need for urgent action will be increased by the greater involvement of primary care practitioners in sexual health screening, which will uncover more latent clinical need that is more likely to further increase GUM workload rather than to divert cases to alternative providers.
Commissioners see the maintenance of open access as a fundamental quality standard of GUM services and may see the Foley patient approach as one means to assess this. By highlighting service deficiencies at this time, Foley et al have stimulated the urgent need for all clinics to review patient access arrangements, challenged the specialty to renew its longstanding commitment to maintain open access services, and provided valuable data to augment our efforts to expand consultant numbers.