Article Text

Short report
Young persons' access to genitourinary medicine clinics in the UK: a cross-sectional survey
  1. Melonie Thomas1,
  2. Kiri Dixon1,
  3. Amer Henry Ali1,
  4. Rajul Patel2,
  5. Angela J Robinson3,
  6. H M Yuen4,
  7. Elizabeth Foley2
  1. 1Faculty of Medicine, University of Southampton, Southampton, UK
  2. 2Department of GU/HIV Medicine, Royal South Hants Hospital, St Mary's Road, Southampton, UK
  3. 3Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
  4. 4Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
  1. Correspondence to Dr Elizabeth Foley, Department of GU/HIV Medicine, Level B, Royal South Hants Hospital, St Mary's Road, Southampton SO14 0YG, UK; efoley{at}doctors.org.uk

Abstract

Study Design This service evaluation of genitourinary medicine (GUM) clinics in the UK was designed to quantify access for young people requesting to be seen and to establish whether they could be seen outside school hours.

Methods In December 2009 postal questionnaires were sent to all lead clinicians in UK GUM clinics asking when they expected a young person would be offered an appointment and whether it could be outside school hours. Between January and March 2010 trained male and female medical students posing as 16 year olds telephoned all GUM clinics listed on the British Association for Sexual Health and HIV website with symptomatic and asymptomatic scenarios and requested an appointment after school hours.

Results 99% of the 152 responding clinicians estimated that an appointment would be offered within 48 h for both male and female contacts and over 90% could be seen outside school hours whether symptomatic or not. Of the 666 clinic telephone contacts, 88% were offered an appointment within two working days, and 66% were offered an after school appointment within 2 days. There was no significant difference whether the ‘patient’ was symptomatic or not (87% vs 86%, respectively, p=0.784) in being offered an appointment within two working days. There was variation between countries, with England performing significantly better; 94% were offered an appointment within 2 days versus 58%, 55% and 67% for Wales, Scotland and Northern Ireland, respectively.

Conclusion The findings would support the impact and value of process targets on service delivery.

  • Adolescent
  • attitudes
  • audit
  • clinical care (general)
  • genital ulcers
  • genitourinary medicine services
  • guideline development
  • gum
  • herpes simplex
  • pregnancy
  • service delivery
  • sexually transmitted disease
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A cornerstone of the improvement in access to genitourinary medicine (GUM) clinics in the UK has been the implementation of clear access targets by the previous government.1 ,2 Within the UK, England Scotland, Wales and Northern Ireland are separate regions with various degrees of devolved government, all of which include health, with correspondingly different policies such that the targets for access to clinics vary. In England the Department of Health (DH) target specified that patients should be offered an appointment within 48 h of initial contact.3 The target for Wales is that all patients should have access to core sexual health services within two working days, and for both Scotland and Northern Ireland that all patients should be able to access specialist services within two working days if assessed as clinically urgent.4–6 These targets were introduced by the respective Departments of Health in each of the devolved countries with financial resources allocated to improve access. Unlike recommendations these targets are laid down in national service frameworks and as such are mandatory. Trusts and health boards that fail to meets these targets are penalised and can have management of that service withdrawn.

In addition, within the national strategy young people have been identified as a key group in which to reduce the prevalence and transmission of sexually transmitted infections (STI).7–9 In England the ‘You're Welcome’ quality criteria for young people seeking any healthcare was introduced in 2007; a key element of this is that services should be accessible outside normal school or college hours.10 The ‘You're Welcome’ paper recommends ‘mystery shopping’ as a good way to assess services for young people. This technique, previously successfully used to measure general access to GUM clinics in the UK, was used to evaluate young peoples' access to GUM clinics.11

Methods

This was a prospective two-part study using postal questionnaires and ‘mystery shopper’ telephone contacts with medical student researchers posing as 16-year-old patients.

GUM clinics as listed on the British Association for Sexual Health and HIV (BASHH) website12 were contacted to confirm opening hours, correct contact details and lead clinician. Clinics open for fewer than 2 days per week were excluded, leaving 222 clinics in the study. Questionnaires (see supplementary appendix, available online only) were sent to lead clinicians in December 2009 with a follow-up reminder sent to non-responders in February 2010. Clinicians were asked if they were aware of ‘You're Welcome’ and whether their clinic was compliant with the quality criteria as defined by the ‘You're Welcome’ criteria scoring toolkit.13 They were asked whether an appointment could be offered within 2 days for four clinical scenarios (asymptomatic male/female and symptomatic male/female patients), who requested to be seen after school hours.

Between January and March 2010, three medical student researchers contacted the clinics on three separate occasions during confirmed opening hours as an asymptomatic woman, a woman with intermenstrual bleeding and a man with urethral discharge and dysuria (to suggest infection with chlamydia). These cases, based on actual clinical histories, were chosen as they displayed symptoms of a common condition in adolescents in which intervention would be required promptly. The researchers were trained to ensure consistency and used terms and language used by young people in the Southampton clinic. Callers asked for a consultation between 15:00 and 18:00 hours but hung up if the telephone was not answered within 3 min. Once the telephone had been answered no clinic was contacted again that week. No actual appointments were made. Information such as date of contact and date of appointment offered were recorded.

To be compatible with the different UK access targets, ‘48 h access’ was defined as within two working days excluding weekends from the initial telephone contact. Individual clinic results were anonymised and data were analysed using SPSS/PASW Statistics 18.0. Data were summarised using frequencies and percentages. The χ2 test or Fisher's exact test was used, whichever was appropriate, to assess the association between two categorical variables. Although ethics approval is not required for a service evaluation, due to the use of ‘mystery shoppers’ we sought the approval of BASHH and the DH. This work was supported by funding from the University of Southampton and a grant from the ‘You're Welcome’, DH.

Results

The questionnaire response rate was 69% (152/222). All clinicians who responded to the questionnaire estimated that 100% of symptomatic patients and 99% of asymptomatics patients would be offered an appointment within 2 days. Furthermore, 90% of female and 91% of male patients would be offered an appointment between 15:00 and 18:00 hours and within 2 days whether symptomatic or not. Eighty-six per cent of respondents were aware of the ‘You're Welcome’ quality criteria, and although 46% were implementing the criteria, only 6% were registered compliant. As expected, outside England fewer clinics were aware of the criteria. Seventy-six per cent of all clinics believed they could either ‘always’ or ‘nearly always’ accommodate a request to see a gender-specific health professional.

All 222 clinics in the UK were successfully contacted with the three scenarios. Of these 666 contacts, 88% were offered an appointment within two working days during clinic time and 66% were accommodated to an after school consultation (defined as between 15:00 and 18:00 hours within two working days). An after school consultation could be offered for 90% of all telephone calls but with up to a 7-week delay. Comparing the responses from the two female scenarios, there was no significant difference between symptomatic and asymptomatic callers in getting an appointment within two working days (87% vs 86%, respectively, χ2 test, p=0.784), nor after school (67% vs 67%, respectively, χ2 test, p=1.000), but a significantly higher success rate in getting an appointment was observed in England than in Scotland, Wales or Northern Ireland (Fisher's exact test, p<0.001); similar results were seen with the after school restriction (Fisher's exact test, p<0.001; table 1). Within England there was little variation between the BASHH regions with the within two working days restriction (Fisher's exact test, p=0.358), but more variation with the after school restriction (χ2 test, p<0.001; table 1).

Table 1

Number (%) of contacts who received a consultation offer displayed by the three medical scenarios, country and the BASHH region in England

Overall, 77% and 43% of the 222 clinics were able to offer an appointment to all three callers both within two working days and after school, respectively, with significantly more clinics in England able to do so (85% and 50% of 186 clinics, respectively) compared with the other three countries (Scotland 35% and 12% of 17 clinics; Wales 33% and 7% of 15 clinics; Northern Ireland 25% and none of four clinics, respectively; Fisher's exact test, p<0.001).

When matching individual questionnaires and the telephone responses, for 90% (405/450) of the cases clinicians accurately predicted that patients would be able to be seen within two working days in their clinic but this was only consistent for 73% (286/392) when the after school restriction was included. Significantly fewer appointments were offered within two working days and after school than the clinicians had expected for almost all countries and BASHH regions (χ2 goodness-of-fit test, p<0.001) except Mersey, Wessex and Thames NE.

Of those not offered an appointment within two working days, 70% (56/80) had not been asked about symptoms. The guidelines in Scotland and Northern Ireland state that a patient should be offered an appointment within two working days if clinically urgent; however, there was no evidence of triage occurring. Clinics that run as ‘walk-in only’ services, that is clinics without booked appointments, were significantly better in offering an after school consultation than those clinics that operated a mixed ‘walk-in’ and appointment service (89% vs 64%, respectively, Fisher's exact test, p=0.001). Female callers were significantly more successful in being offered a consultation with the same gender compared with male callers (78% vs 48%, respectively, Fisher's exact test, p<0.001).

Discussion

This service evaluation based on three contacts with each NHS GUM clinic provides a summation of over 600 clinic contacts and identifies a number of differences between services, patterns of limited service availability and incongruities among staff expectations and the actuality of service provision.

The majority of UK clinics can offer a consultation within two working days and accommodate a request to be seen after school hours, but there is a disparity between the expectations of lead clinicians who expect better of their services than our study findings indicate. There was marked variation among UK countries, with England performing significantly better than the devolved nations. The performance management of English services against the 48-h target may explain this, while this is not the case in Scotland and Northern Ireland. However, both the Scottish and Northern Irish national targets specifically advocate the prioritising of some clinical presentations.9 ,10 Such guidance was not demonstrated as having an impact on service provision with little effort at triage being demonstrated by clinics in these countries before offering an appointment after 2 days.

One of the limitations of this evaluation is that it only represents a snapshot; however by using a ‘mystery shop’ evaluation it provides novel information about the difficulties patients may encounter with access to GUM clinics. Furthermore, the medical student researchers were older, well educated and possibly more eloquent than a ‘real’ 16-year-old and so this study may under-report the real difficulty an individual may encounter. However, as fewer than one-third of callers were asked about symptoms it may be more of a reflection of overall clinic capacity. The ‘You're Welcome’ quality standards only refer to clinics in England and are not required or applied in the other devolved nations; however, these quality criteria, as judged by lead consultants' responses essentially reflect core GUM service values. Finally, as this is an ecological and cross-sectional study, causation although suggestive cannot be inferred.

With the change of emphasis to outcome measures rather than process targets, one key STI control measure of rapid access to clinics for diagnosis and treatment may be lost. Ease of access forms an important part of most STI prevention programmes, and is one that can be monitored easily and is wholly within the remit of service providers, unlike other parameters such as sexual behaviour. Rapid access must be maintained and continue to be monitored—our study demonstrates that services do not necessarily perform as well in prioritising those most in need of urgent consultation, and lead clinicians often have an over-expectation of their own services delivery.14 Service providers within Scotland, Northern Ireland and Wales may also wish to reflect on whether their services are best configured to provide easy and open access to young people.

Key messages

  • A key feature of the improvement in access to Genito-urinary medicine (GUM) clinics in the UK has been the implementation of clear access targets with the allocation of financial resources by the previous government.

  • Ease of access forms an important part of most STI prevention programmes. It can be easily monitored and is wholly within the remit of service providers, unlike other parameters such as sexual behaviour.

  • GUM clinics in the UK were ‘mystery shopped’ by researchers posing as 16 years old requesting to be seen as soon as possible.

  • 88% of clinics offered a consultation within two working days with 66% accommodating a request to be seen after school hours but there was marked variation among UK countries with England performing significantly better than the devolved nations.

  • With the change of emphasis to outcome measures rather than process targets, one key STI control measure of rapid access to clinics for diagnosis and treatment may be lost.

  • This study suggests that rapid access should continue to be maintained and monitored.

Acknowledgments

The authors would like to thank Miss Claire Swarbrick for her help with the study design.

References

View Abstract

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:

Footnotes

  • Funding Permission for this service evaluation was granted by the Department of Health (DH) and supported by an educational grant from ‘You're Welcome’ DH.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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