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Abstract
Background A key aim of England's National Strategy for Sexual Health is to extend high-quality sexual health services in primary care.
Objectives To explore the expectations and experiences of men and women who initially presented at their general practice with a suspected sexually transmitted infection in order to identify areas where change could improve service delivery.
Methods Semi-structured interviews were carried out in six general practices and two genitourinary medicine (GUM) clinics in Brent primary care trust (London) and Bristol (southwest England). Patients within general practice, and GUM patients who had initially attended general practice were eligible to participate. Interview transcripts were analysed using thematic analysis.
Results 49 patients (29 women, 20 men) were interviewed. Patients approaching their GP practice typically expected written referral or in-house care, but this expectation was often not met. Absence of formal referral, lack of information and perceived avoidance of sexual health matters by practitioners were commonly cited as reasons for disappointment. However, a dedicated service within general practice met expectations well.
Conclusion Purchasers and providers of all general practice services should ensure that any patient consulting in primary care with a suspected sexually transmitted infection can either receive appropriate care there, or a formal and supported referral to a specialised GUM clinic or primary care service.
- Family practice
- sexually transmitted infections
- general practice
- qualitative research
- health service research
- HIV testing
- primary care
- STD patients
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- Family practice
- sexually transmitted infections
- general practice
- qualitative research
- health service research
- HIV testing
- primary care
- STD patients
Introduction
Diagnosed rates of bacterial sexually transmitted infections (STIs) in the UK have more than doubled since 1995.1 The National Strategy for Sexual Health and HIV lifted sexual health up the political and healthcare agenda in England2; it encouraged improved access, patient information and choice in sexual health services, particularly in primary care. More recently, the National Institute for Health and Clinical Excellence recommended that health professionals in a variety of settings, including primary care, provide a one-to-one counselling session about preventing STIs and under-18 conceptions for individuals at high risk.3
General practice is already an important provider of STI care in the UK, providing an increasing proportion of STI diagnosis and treatment,4 reaching up to 30% for chlamydia and genital warts.5 About a third of new patients seen in genitourinary medicine (GUM) clinics have initially gone to their general practitioner.6 Many of these patients reported that they had not been examined or had any tests done.7 8
Little is known, however, about the experiences of patients who remain in general practice, or are referred to GUM clinics but do not subsequently attend. We aimed to describe the expectations and experiences of patients presenting to general practice with STI-related problems.
Methods
Population and sampling strategy
The study took place in the contrasting populations of Brent, in North West London, and Avon, in the southwest of England. The population of Brent is ethnically diverse: 55% are from non-white ethnic groups by contrast with <10% in Avon.
Recruitment of healthcare settings
We started by identifying practices serving populations likely to have high levels of sexual healthcare needs, as indicated by teenage conception rates and deprivation scores above the median for the locality. Within this group of practices we then used district laboratory data (up to 2005 for Brent and up to 2004 in Avon) to calculate rates of testing for chlamydia and HIV. We used these measures as proxy indicators of the level of involvement in providing sexual healthcare. In Brent we were also able to identify practices with high referral rates to GUM clinics accompanied by low testing in the practice, using data from a previous study.6 We initially approached practices in each area known to have either high or low rates of testing (above and below the median for the area) to take part in the study, in order to recruit patients with diverse experiences.
We also enrolled participants from the main GUM clinic serving each area so that patients who had presented in primary care but gone on to attend a GUM clinic could be included.
Recruitment of patients
General practice
Patients aged ≥16 years with a diagnosed or suspected STI whose first presentation was at a participating general practice were eligible, with a planned maximum of 30 interviews. We explained the purpose of the study to staff in each general practice and agreed on a method for enrolling participants. Owing to the unpredictable timing of potentially eligible consultations a researcher could not be present at all times, so GPs and practice nurses invited patients to participate during the consultation, obtained written consent and sent a copy of this to the researchers with a contact telephone number. Practices were asked to approach all eligible patients. However, we were not able to monitor the number of eligible patients or the number who refused to take part, as no suitable register of cases was available. Researchers made up to three attempts to arrange a suitable time for a telephone interview. Participants were sent a £15 postal order thank you gift after the interview.
GUM clinics
In each GUM clinic, a researcher recruited participants at a range of clinic session types (walk-in, young people and booked appointments). Reception staff identified patients aged >16 years who had already seen their GP for their current problem. The researcher approached all eligible patients, obtained written informed consent and undertook interviews during the clinic visit. Initially, 30 interviews were planned, but this was increased to 38 since practice-based interviews proved difficult to arrange.
Interviews
The interviews were semistructured, based on a topic guide which explored basic demographic information and relationship status, reasons for initially attending, experience of accessing care, consultation, referral and treatment, views about the service received and preferences for future care. Both telephone and face-to-face interviews lasted between 25 and 30 min, were audio-taped with permission, labelled with an identity number to protect confidentiality and transcribed verbatim. Data analysis followed the ‘framework’ approach, which involves a structured process of ‘sifting, charting and sorting’ material according to key issues.9 Recurring themes and concepts were identified to make up a thematic framework, or index, which was then applied systematically to the transcripts. LJS and KES undertook the analysis. Reliability was enhanced by double coding and comparing a subset of transcripts. Few discrepancies emerged and, where they did, consensus was negotiated.
Results
Recruitment
Six of 16 general practices approached agreed to participate, split equally between Brent (3/71) and Avon (3/143), together with both local GUM clinics. However, we were unable to enrol any practice in Brent with chlamydia testing rates below the median for the area. Forty-nine interviews were conducted between July 2005 and March 2006. In general practice we interviewed 11 (nine women, two men) of 22 patients who agreed to be contacted; the other 11 could not be contacted on the telephone number provided. In the GUM clinics all 38 (20 women, 18 men) patients approached agreed to be interviewed. We could not determine overall participation rates in either setting because we did not know the total numbers of eligible patients.
Characteristics of the sample
The characteristics of participants are summarised in table 1. The median age of general practice patients in Bristol was lower than in other settings because most of them were enrolled from a more specialised ‘locally enhanced’ sexual health service that had links with local schools. While most participants in Bristol (26/27) were of White British ethnicity, 11/16 from Brent who reported their ethnic group were from Black or Asian minority ethnic groups. About a quarter of all participants from GUM clinics but none from general practice were married or cohabiting. Most participants reported one sex partner during the past 3 months; the two men interviewed in general practice reported ‘three to four’ and two partners. Of 11 patients enrolled from primary care, nine had been wholly managed in that setting.
Patient characteristics by geographical area and setting of enrolment
In all settings, participants presented variously with genital tract symptoms, reported symptoms in a partner and requesting a check-up following risky behaviour or between relationships.
Three main themes emerged from the thematic analysis.
Theme 1: Accessing general practice
Most respondents had chosen to go to their GP first because of perceived speed and ease of access, particularly those who had used GUM services before and had had difficulty getting an appointment.
“The reason why I hadn't got checked out earlier is just trying to get an appointment in an STI clinic is very, very hard, especially when you're working full time. And even though they sometimes have a drop in time to go there, but sometimes it's not actually convenient times when you're working.”
[Female, 27 years, GP practice]
“Because it's difficult, it's like a rat race here [GUM clinic] at 9 o'clock in the morning and when I've just arrived at work, you know, spending all the time on the phone it just really didn't go down too well”.
[Female, 26 years, GUM clinic]
One general practice in Bristol provided a locally enhanced service for sexual healthcare. Participants enrolled from this practice said that they chose this service because the practice nurse also ran school drop-in sessions and sex education lessons and they perceived her as a ‘specialist.’
“I'd always choose to go to the Locality Centre because it is kind of… I feel it's more suitable like youth-based and I feel like they've got more time kind of thing if I need it. Because I know that GP clinics are busy and trying to get an appointment… you know it can be hard work… and also I know the nurse as well. She used to come to my school when I was at school and she used to give sort of, well she'd, she'd do a No Worries session then.”
[Female, 18 years, GP specialist clinic]
“Because it's the same lady that does the swabs, the testing as the one in the [GUM] clinic, she does it in the hospital as well.”
[Female, 16 years, GP specialist clinic]
All respondents reported that it had been easy to book an appointment at their general practice and many were seen within 48 h of first contact. While some women waited longer because they preferred to see a female doctor, men did not seem to mind the sex of the doctor.
Theme 2: Patients' expectations and experiences
Many of the young patients enrolled from the in-house ‘enhanced’ sexual health service in Bristol reported initial nervousness but all were happy with the outcome.
“Well I went in there, she asked me why I wanted to go, when was the last time I slept with someone and everything. And then I had to lie down on the couch and then I had to take my trousers and boxers down then they just took a swab and like felt around the area to see if there's any pain or whatever or any unusual lumps or something. At first I was a bit uncomfortable with it but then I just got used to it…….really there ain't really nothing to be embarrassed about, at least they know that you're actually checking up to be sure.”
[Male, 20 years, GP specialist clinic]
Patients enrolled from all other settings reported mixed expectations and experiences at their general practice. Participants reported that they expected to receive information about their condition or symptoms verbally or in a patient information leaflet, yet many received none. This emerged as an important influence on their satisfaction with the service received. Many patients also felt that the GP avoided discussing sexual health matters with them.
“They just don't look at you, they just look at the computer….she should tell me because she is my GP and I don't know about these diseases, she knows. She got an education for that and she is therefore our service”.
[Male, 30 years, GUM clinic]
Participants often expressed surprise that they were not questioned about their sex partners, use of condoms or previous STI at the general practice consultation. Many men and women had a physical examination but a few had tests or swabs taken, usually for chlamydia and occasionally for gonorrhoea. For the majority of participants this was a disappointment as they had thought they would be able to be tested for all STIs. Often they referred themselves to the GUM clinic after the GP consultation because of this.
“I think that's the perception people get that when you go to see your GP you expect to maybe have all your treatment there”.
[Male, 32 years, GUM clinic]
“I thought they'd give me more advice or—I don't know I went there and they just, she was so well you need to go to the GUM clinic we can't do it here, which I thought was like—because my friend had been to the same doctor's as me and she had it done there”.
[Female, 23 years, GUM clinic]
Several participants spontaneously mentioned having requested an HIV test, or being surprised that this was not offered. One of these had requested an HIV test but had been refused for incorrect, outdated reasons.
“She [the doctor] said that it would be better if I didn't have it [HIV test] done at the doctor's surgery because if I wanted to apply for a mortgage or some sort of house insurance policy it would obviously all be logged and I would be better off going to like a hospital where you're slightly more anonymous. If I could have just done the whole thing together in one fell swoop I would have just done all of the tests altogether… but now you know the chances of me going down and queuing up one morning at hospital before work or whenever I probably won't do it, I won't I know I won't. I mean I haven't done it and that was a couple of months ago that I had the other things done at the doctor's surgery”.
[Female, 35 years, GP practice]
Several participants (n=7) had attended with an expectation of referral to a GUM clinic by letter. Generally these patients were given a telephone number for them to call, and they often said they would have felt more confident turning up at the GUM clinic with a referral letter in their hand. Those who were given a referral letter or for whom the GP made a GUM clinic appointment described attending the GUM clinic more quickly than those who had only been told to attend or were given a phone number to call the GUM clinic themselves.
Patient:“She just give me the number for ……. (GUM clinic) and said you have to go to a special clinic.”
Interviewer:How did that make you feel then?
Patient:I thought, ‘Oh I'm scared’, and I don't know, I just felt you know obviously she don't know what she's talking about so I have to go into one of these places.
Interviewer:So how did you feel after you'd come out of that appointment?
Patient:I wanted to cry, someone, what's going on?
Interviewer:Why did it make you feel you wanted to cry?
Patient:Because she was no help at all. You know being a doctor you should be more caring. These things happen she should be more caring; she could have booked the appointment or given me a letter or something, then I'm thinking, ‘Oh I'm going to come here [GUM clinic] and it's going to be like this again.
[Female, 23 years, GUM clinic]
Theme 3: Expectations and preferences for future STI-related care
Participants were asked where they would prefer to seek treatment in future if they experienced a sexual health problem. All saw primary care as their preferred source of help, including those who had been referred on to the GUM clinic. Their reasons included convenience, ease of access, having a good relationship with their GP and satisfaction with past consultations. Most participants did not want a designated clinic time, preferring to be treated during normal surgery.
“In an ideal world the general practitioner would be an expert in everything [laughs] which I think you know isn't possible, but that would be my ideal, for me personally, although the awkwardness is still there it kind of takes away the stigma, which is probably really old fashioned, but yeah it's just that thing you know it's embarrassing to you know—I don't know anybody in the area but there's always that thing in the back of your mind what if somebody sees me going in”.
[Female, 29 years, GUM clinic]
“You sit here and everyone knows why you're here. At least at the doctor it could be a case of you've got a bad back or something”.
[Male, 25 years, GUM clinic]
However, when asked where they would in fact go to get treatment for a suspected STI again, most participants said they would choose the GUM clinic, perceiving its staff to be ‘specialists’ and expressing high levels of satisfaction about the information, tests and advice received before, during and after their consultation.
“I would suggest you go there first then everything, you get everything sorted out on the same day, don't have to wait for your results, wait a week for your results and wait a week for your prescription”.
[Female, 22 years, GUM clinic]
Discussion
This study showed that patients who approach their general practice seeking care for a possible STI typically expect either written referral or in-house care, but an absence of formal referral, and lack of information, were often cited as unmet expectations. Informal referral to a GUM clinic, without a letter or appointment, was experienced as stressful and disappointing, and often led to avoidable delay in care. A lack of detailed sexual history taking in general practice in this context was surprising to these patients, who often felt that practitioners were avoiding the subject.
Few studies to date have dealt with patient experiences of sexual healthcare received in general practice in detail.7 10 Structured questionnaire surveys of patients in GUM clinics have found, however, that a substantial proportion would have preferred to have had their problem managed in primary care.10 We also found that patients expected their GP to examine them and ask questions about their sexual history. This finding makes more surprising other surveys which report that up to three-quarters of primary care staff refer patients with a suspected STI to GUM clinics without a consultation,10 and that of those receiving a consultation, most do not have tests for STI or are not examined.7 The perception by many study participants of a lack of confidence in primary care staff concurs with other studies reporting reluctance by practitioners to deal with sexual health problems, with less experienced practitioners only considering an STI as a last resort.11 12 Primary care practitioners taking part in focus groups to discuss chlamydia screening have suggested that it is patients who are reluctant to have tests taken or to have sexual health problems recorded in their notes.11 Our study seems to contradict this since patients reported that they expected details of sexual histories to be recorded, investigations to be done and referrals to be made formally.
A major strength of this study was that we obtained ‘consumer’ data about expectations and experiences of accessing sexual healthcare relevant to a range of settings and populations. Our recruitment of practices was based on demographic and laboratory data, focusing on high sexual health need. In doing so we reduced the ‘enthusiast’ effect as far as possible. However, we were unable to recruit a low-testing practice in London. We were disappointed at how difficult it was to recruit patients, particularly men, in the non-‘enhanced’ general practice setting, despite extensive efforts. There are a number of reasons for this, which reflect wider difficulties in studying single-episode conditions in primary care.13 Unless the practice has some kind of enhanced sexual health service—and even if it has—eligible patients form a small group presenting at unpredictable times, in busy practices. They are therefore hard to recruit without a dedicated researcher who would be unoccupied for much of the working week. Our general practice patients cannot be considered fully representative of the eligible population, owing to these difficulties in recruiting patients with a single episode, stigmatised condition in a practice without some kind of special provision for sexual health.
A possible mode effect in the interviews must also be taken into account in assessing our results. Since general practice patients were geographically dispersed, they were interviewed by telephone. It is hard to predict how this might have affected the findings or patterns of recruitment.
Our findings suggest that there is often a substantial mismatch between patient expectations and experiences when attending general practice with a possible STI. While patients did not necessarily expect comprehensive management in primary care, dissatisfaction focused on a few key issues—lack of formal supported referral, lack of information and lack of engagement with the patient on sexual health. Yet the experiences of the subset of patients drawn from a specialist service within general practice confirm in a non-experimental setting the feasibility of acceptable STI management in this setting. In a qualitative study of patients diagnosed with chlamydia on home-taken specimens but treated in primary care, high levels of satisfaction with the management provided by practice nurses were also reported.14
Our study shows mismatches between the expectation of patients and the care they actually received, and between patient expectations and the different concerns of general practitioners reported elsewhere in the literature. These divergences should now guide service provision. Study participants often reported ‘informal’ referrals to GUM clinics, in which they were told to approach a second service without a letter or telephone call. GPs may still perceive GUM clinics as being embarrassing places to go, and think that ‘anonymous’ referrals are preferred. This would be consonant with the occasional persistence of outdated beliefs that patients will not be able to get life insurance if they have been tested for HIV, which are still sometimes offered as explanations by GPs for not managing sexual health problems in primary care. This suggests that recent modernisation of sexual health services15 needs to be better publicised among professionals. This would be helped if purchasers of primary care explicitly commissioned services specifying pathways from primary to secondary care. It could help to achieve the timely evaluation and treatment of symptomatic patients that are important contributors to STI control.16 While highlighting scope for improvement, our results also question a recent emphasis on the establishment of ‘locally enhanced services’ in some practices.17 Without establishing effective and formal referral from the many practices which do not provide testing, many patients may continue to fall between services, resulting in persistent infection and onward transmission.
Our findings have been used to inform the development and piloting of a low-cost intervention aimed at helping GPs improve the care and experiences of patients attending general practice with a suspected STI. The intervention includes a web-based portal that GPs can use to print out information leaflets for patients and referral letters. This kind of approach might provide an opportunity to ensure effective management for STI within primary care or successful supported referral to specialist services. At the population level, one or the other must be universally offered if each patient is to be directed quickly into curative treatment, and STI control enhanced. Standardised packages are now available for training general practice staff in the UK, which should now emphasise these findings and incorporate them into the training. The incorporation of these findings into low-cost structural interventions—for example, by commissioning services that are required either to formally refer on or provide a full package of care—could have an important impact on patient experience and on outcomes.
Key messages
Patients attending general practice for sexually transmitted infection related care generally expect to receive appropriate care or a formal referral to other services.
Where patients attending general practice reported disappointment with care, this usually related to lack of formal referral, lack of information or perceived avoidance of the subject by practitioners.
Commissioning of general practice based care should focus on ensuring that all patients have access to comprehensive care in practice, or through supported referral.
Acknowledgments
The authors wish to thank all health professionals in the general practices for consenting to eligible patients attending interviews. We thank the GUM clinic staff for their support throughout the study period, in particular the receptionists for assisting in the identification of eligible patients. We thank Lynn Myers for help in designing the topic guide.
References
Footnotes
Funding This work was funded by the 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.
Statement of independence from funders The Medical Research Council has 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 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 CaPSTI study was approved by the South-West Multi-Research Ethics Committee (reference number 05/MRE06/9).
Provenance and peer review Not commissioned; externally peer reviewed.