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Military personnel are considered to be at high risk of sexually transmitted infections due to their being highly mobile, away from home for prolonged periods and often purchasers of commercial sex.1 Indeed, evidence from the USA has demonstrated higher rates of gonorrhoea and chlamydia in active soldiers compared with the civilian population after standardisation for age and gender.2
Having acquired a sexually transmitted infection (STI), military personnel risk onward transmission to the civilian population, including their regular partners. Despite health promotion and provision of condoms, STIs continue to affect military personnel, necessitating measures for their early diagnosis and treatment.
The British Forces in Germany (BFG) community comprises military personnel, their dependents and the civilian support staff. In 2007, BFG comprised approximately 46 000 individuals living in an area approximately the size of Scotland. The number steadily declined to approximately 36 000 people by 2012. This population is generally that of young, fit individuals with a high proportion of children and young people (75% are aged <35 years). Historically, members of the British forces have earlier coitarche, a higher number of sexual partners and report less condom use than their age-matched UK civilians,3 and are more likely to pay for sex.4 In Germany, there is easy access to licensed brothels, and an acceptance of ‘layby lils’, commercial sex workers who trade from roadside camper vans.
In 2007, access to STI services in BFG used a traditional consultant-led model. This centralised genitourinary medicine (GUM) service was provided by a one whole-time equivalent (WTE) consultant supported by three or four WTE specialist civilian/military nurses. Primary care encouraged attendance at the GUM service for all STI matters, including asymptomatic screening, despite patients having to travel considerable distances.
In 2008, the contract for GUM services for the BFG population was awarded to a limited liability partnership of Soldiers, Sailors, Airmen and Families Association (SSAFA) Forces Help and Guy's and St Thomas’ NHS Foundation Trust. This triggered a review of the centralised model of care identifying the need to reconfigure services based on the specifications for different levels of sexual healthcare5 and to increase accessibility to these by implementing the appropriate ‘10 high-impact changes’6 as outlined by the UK Department of Health.
Addressing the key priorities for service reconfiguration
Recognising the priority for the integration of sexual health service provision with primary care/community services, a Sexual Health Steering Group was formed comprising representatives from existing GUM service, primary/community care, professional leaders and managers. The Steering Group made the following assumptions:
Asymptomatic patients would be least likely to travel long distances to visit central GUM clinics, and would access screening services via their general practitioner (GP).
Patients with symptoms and those few preferring not to access services through their GP perhaps due to concerns about confidentiality would be happier to wait/travel further to access specialist clinics.
Those with complex problems, such as HIV, would prioritise access to expertise.
A commissioned user focus group run by a marketing expert confirmed that soldiers were happy to consult their GP for sexual health matters; indeed, they were often the first point of contact before referral to GUM services. Furthermore, most felt there was no need for additional levels of confidentiality. Perhaps accustomed to acceptance, the soldiers offered few suggestions for service improvement. This limitation might be overcome by using methodologies collecting anonymised responses.
Integrating genitourinary medicine (GUM) services with primary care
Establishing a nurse-led tertiary GUM service with open access and remote GUM consultant support
With the primary care team required at the forefront of sexual health service delivery according to the service model outlined (box 1), the Steering Group recognised the need for education, which was provided by way of Sexually Transmitted Infection Foundation (STIF) courses, designed specifically for non-genitourinary healthcare workers, and accredited by the British Association for Sexual Health and HIV (BASHH).7 The course was delivered by experts from the local and London-based GUM teams, and supplemented by clinical placements, which further forged relationships between primary care and specialist GUM staff. Indeed, education has been linked with increased testing for STIs, although there is variability in testing pattern changes for specific diseases.8 ,9
On the retirement of the incumbent 1 WTE sexual health consultant in 2009, an opportunity emerged to review the provision of sexual health services. A nurse-led service was envisaged with remote consultant support provided by a London-based GUM consultant. This model of care was considered to be more cost-effective than a traditional consultant-led model and in line with UK recommendations.6 In the UK, nurse-led community clinics are popular with younger age groups10 and considered to be an acceptable alternative to doctor-led clinics.11 Furthermore, analysis of clinic workload has shown that the case mix is similar to that seen in main GUM clinics with the vast majority of cases able to be managed in the community by specialist nurses without medical staff on site.12 The specialist centre would continue to offer open access for anyone who preferred to access its services directly, and it would provide support to primary care staff delivering STI services.
Within the GUM service, service reconfiguration fuelled fears related to potential loss of employment and the future of the existing service. This change management required an active approach that facilitated staff engagement through focus on patient outcomes and clinical effectiveness in partnership with a focus on their own personal and professional development. Engaging the local team with the delivery of the STIF course further enhanced the personal and professional profiles of the specialist nurses, which in turn improved morale and engagement.
Two experienced level 3 specialist GUM nurses were supported to see patients independently with clear pathways of remote support for more complex cases. The remote consultant, and through her the expertise of the Departments of Sexual Health and HIV at Guy's and St Thomas’ NHS Foundation Trust, were available during all working hours by email and telephone. The consultant travelled to Germany once a month to run two half-day clinics to review patients who could not be managed remotely as well as to support service management and governance activities. The latter was supported by a local 0.1 WTE manager (box 2).
Key requirements for service reconfiguration
Internal and external stakeholder engagement: incumbent genitourinary medicine (GUM) team, primary care, service users, managers
Training of primary care staff to provide level 1±level 2 sexual healthcare
Support for primary care sexually transmitted infection service providers through local GUM nurses
Upskilling of local GUM nurses to provide level 3 care
Remote access to GUM and HIV specialists/multidisciplinary team
Evaluating the service reconfiguration
As part of the roll-out of the STIF course, around 90 primary care staff were trained. Each course received an average rating of 4.5/5.0 on a Likert scale assessing delegate satisfaction (5=very good, 1=unhelpful/poor).
When evaluating the impact of service reconfiguration, a number of key parameters needed to be considered, which are summarised in table 1:
changes in population size and demography as these may be confounding variables;
number of tests performed in total and by service type to determine the actual change in testing;
proportion of tests performed by service type to determine relative contribution of different service type to population testing;
proportion of positive tests to determine if high-risk population is being targeted for testing.
In summary, the number of tests performed increased despite the decrease in overall population size, reflecting increased testing in those aged <35 years. The reduction in the proportion of chlamydia-positive samples could be explained by higher asymptomatic screening after the service reconfiguration, much of which was led by GP. Increase in testing by GP did not decrease testing in GUM services.
The service reconfiguration achieved a cost-efficiency saving of around £55 000 per annum.
We believe we have developed a model, which delivers increased testing for STIs in a high-risk, widely dispersed population while simultaneously reducing costs without compromise to standards of patient care. We have moved from a traditional consultant-led model to a nurse-led model working collaboratively with primary care. Consultant support, although mainly remote, is able to provide the necessary expertise to guide/support practice.
This model differs from others in that specialist nurses facilitate service development in primary care, building a close relationship with primary care providers and shared governance arrangements.
We consider this model could be replicated in other widely dispersed, low-population-density settings.
Handling editor Jackie A Cassell
Contributors JEL and CSB devised the model and ran the service. They also cowrote the paper with MD and MS. MD, MS and SPS compiled the figures, tables and statistics. DPB and PBL delivered the model and suggested modifications. The British military chain of command approved the paper.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.