• patient access
• genitourinary

We read with interest the article published by Cassell et al¹ about the maintenance of patient access to genitourinary medicine (GUM) clinics following a switch to an appointment based system. Their data show no significant change in the age, ethnic mix, symptom status, and disease mix following the change to appointments. In addition, such a system of 35% prebooked appointments produced an increase in the number of patients seen over that time.

A new appointment based system was introduced at the John Hunter genitourinary medicine clinic at the Chelsea and Westminster Hospital in October 2001. This comprised 80% of appointments which were prebooked with a further 20% allocated on the day following triage by a nurse. All patients with symptoms were seen on the day of presentation.

We have analysed the results from two 9 month periods, taken immediately before the change and 3 months after the introduction of an appointment based system. The total number of patients and sex ratio seen over this period did not change. We have shown however a dramatic change in the number of STI diagnoses made over these two periods.

Tables 1 and 2 highlight a significant fall in the total number of STI diagnoses for gonorrhoea (B1), uncomplicated chlamydia (C4a, C4c), non-gonococcal urethritis (C4h), and first attack of genital herpes (C10a) in our male patients. The only significant fall for women was seen in the diagnosis of a first attack of genital herpes. There was no significant change for both sexes in the diagnosis of anogenital warts (C11a) between the two systems. The rise in primary diagnosis of syphilis (A1) reflects the beginning of the current epidemic in London, boosted further by a proactive approach to diagnosis in our HIV positive population.²

This fall in acute STI diagnoses in men was approximately twice as marked for men who have sex with men (data not shown).

Our aim in planning the change to a primarily appointment based system was to improve patient experience, by reducing waiting times, and enhance access for symptomatic patients into reserved appointment slots. These data show evidence for an opposite effect which we believe has resulted from asymptomatic individuals requiring sexual health screening booking the majority of clinic appointments well ahead of their appointment, thereby reducing access at convenient times for symptomatic individuals who telephone.

To respond to this we have adjusted the ratio of prebooked versus emergency appointments and significantly amended our approach to triage of symptomatic patients, in an attempt to reverse these trends. Particular attention is now being given to our telephone booking protocol to facilitate symptomatic patients to achieve prompt, immediate appointments. We are publishing these findings to inform others who are implementing changes in clinic appointment schedules, designed to enhance access, to better tailor the booking and triage systems to achieve this goal. We will continue to audit our system to examine the effect of the revised system and to further examine why the change to our appointment system disproportionately affected those men who have sex with men.