Memorandum by the Speciality Societies
for Genitourinary Medicine
The clinical discipline of Genitourinary Medicine
is the principal provider of specialist clinical services for
the management of sexually transmitted infections and HIV throughout
Although there is a recently released implementation
plan for the national strategy for sexual health and HIV, there
are concerns that there is insufficient prioritisation of resources
given the threat of a heterosexual HIV epidemic fuelled by lack
of control of other sexually transmitted infections.
The clinical demands placed upon GU Medicine
clinics have rapidly increased during the past five years in response
to changing lifestyles and the rising incidence of STIs. The annual
numbers of newly diagnosed HIV cases have increased because of
continuing transmission within the UK augmented by the detection
of infections in persons originating from high prevalence countries.
The removal of sexual health from national health
priorities has resulted in a virtual stalling of consultant expansion
and absence of new investment in GU Medicine services with which
to meet this increased demand.
The ideal of immediate open-access services
to prevent onward transmission of communicable diseases is no
longer possible within clinical services that are working beyond
their safe capacity. Waiting times for new appointments have increased
to a median value of 14 days throughout England. Over 40,000 patients
are currently experiencing unacceptable delays in accessing services.
This has many adverse health consequences for
individuals and communities as well as serious economic consequences
for future healthcare expenditure. The effects of poor service
access will be inevitably felt most by the young and those who
are from socially disadvantaged communities. Thus, inadequate
provision of services and delays in GU Medicine clinic access
are exacerbating inequalities in sexual health and jeopardising
clinical governance requirements.
Support for training and education of primary
care practitioners, and for the further development of local networks
of sexual health services is also being impaired.
We have advised both government and the Department
of Health that the national health education and HIV testing campaigns,
even of a targeted nature, will inevitably increase clinic workload
that cannot be met by currently available resources. The additional
£5 million allocation is not recurrent and will not allow
employment of permanent staff. A coherent medium-term plan to
develop service manpower and infrastructure is needed if the strategy
aims and national targets are to be achieved.
1. Public health services for the clinical
management of sexually transmitted infections (STIs) were first
established in 1917. Since then, a UK network of over 250 clinics,
led by consultant physicians in Genitourinary Medicine, has evolved
which is held in high regard within Europe and beyond.
Features of services
2. The service is open-access, so that patients
can self-refer, provides free treatment, and is characterised
by confidentiality, non-judgmental attitudes, the availability
of immediate diagnostic tests supported by sophisticated microbiological
investigations, and support for contact tracing. Secondary prevention
activities also include one-to-one health promotion, advice upon
risk reduction strategies, and partner management. Ideally, there
should be no waiting lists because rapid diagnosis and treatment
is essential to prevent onward transmission of STIs and the avoidance
of costly complications.
3. GU Medicine is also the main provider
of HIV diagnosis and treatment, although in some locations HIV
care is also provided by other medical specialities. The presence
of STIs facilitates the transmission of HIV, hence public health
control of STIs is an essential feature of HIV control programmes.
4. GU Medicine clinics provide many other
sexual health services including contraception, colposcopy for
the early diagnosis of precancerous anogenital cancers, erectile
dysfunction clinics, and services for victims of sexual abuse.
There are many clinical linkages with other medical specialities
related to inpatient care of STI and HIV complications. There
are also increasingly close community links with other sexual
health services, including sexual health promotion, contraception,
and psychosexual services.
5. The multidisciplinary clinic staff of
GU Medicine clinics is consultant-led. Consultants undertake their
initial training in general medicine and gynaecology and then
must complete four years of specialist training in the discipline
to gain their certificate of completion of specialist training
(CCST). About one third of the total consultants are single-handed,
some covering more than one site, and with more than one employer.
This is unsatisfactory for clinical governance.
6. Consultants are supported by doctors
in training (predominantly in teaching hospitals), and /or by
non-consultant career grade doctors and/or GP clinical assistants.
In larger clinics, there is dedicated nursing staff but these
may be shared with other specialties where the service is not
Health advisers, who are derived from a variety
of disciplines, usually nursing, take the major role in contact
tracing and partner notification, and also have important roles
in epidemiological surveillance, health education and in counselling/support
of HIV patients.
The clerical and receptionist staff have a vital
role as the first point of contact for patients.
In larger clinics, dedicated psychologists,
pharmacists, and social workers may provide additional patient
support especially, where there is a high HIV workload.
7. The growth of academic centres for GU
Medicine has lagged behind other disciplines. There are now three
professorial units in London and one in Liverpool.
Numbers of new patient attending and total attendances
8. The annual number of new patient episodes
in England, Wales, and Northern Ireland doubled between 1990-2000
to a total of around 1.2 million. The capacity of clinics to provide
optimal care has now been exceeded. Very few clinics are now able
to offer immediate care for all who present and waiting times
for new patient appointments have become unacceptably long.
9. Although STIs are more prevalent in London
and major conurbations, the excessive pressures on clinics has
occurred throughout the UK and poor access is widespread.
10. During 2002, the unprecedented demand
for GU Medicine services has increased with a corresponding deterioration
in patient access times, especially in larger cities. The median
time to first appointment in 2002 has lengthened to 12 working
days for men and 14 working days for women, compared with five
and six days respectively in 2000 when concern was first expressed.
The numbers of new patient appointments attending GU Medicine
clinics each week is around 15,000. Thus, the number of new patients
currently waiting unacceptably long to be seen is now in excess
of 40,000 and continuing to grow.
11. For most GU Medicine clinics, the numbers
of women attending exceeds that of men; appointment delays are
longer because of their longer consultation times. Delays for
urgent cases are also more likely to affect the young, those from
deprived communities, and others less able to negotiate immediate
attention especially where English is not their first language.
Increasing incidence of STIs and HIV
12. The incidence of STIs and HIV appears
to be rapidly increasing.
(a) Outbreaks of infectious syphilis, previously
a rare and usually imported bacterial infection, have occurred
in many parts of the UK. They have now spread to other towns and
cities from outbreak epicentres, especially in the North of England
and London. The numbers of annual cases more than doubled between
1995-2000, and provisional CDSC figures for 2001 show a further
doubling of cases compared to 2000.
(b) Cases of infectious syphilis are now
appearing in women and we fear that congenital infection will
reappear in neonates, as happened in similar circumstances in
the USA during the 1990s.
(c) The incidence of gonorrhoea, including
antimicrobial resistant infection, is increasing. Cases diagnosed
in GU Medicine clinics doubled between 1995-99, and preliminary
analyses suggest a further 16 per cent increase has occurred between
(d) Diagnosed cases of the commonest bacterial
STI, chlamydia, also doubled between 1995-99 and further increased
by nine per cent during 2000-01. Many clinics are reporting increases
in the number and proportion of complicated cases, consistent
with deteriorating access. In most parts of the UK, adolescent
women who have the highest prevalence of chlamydial infection
do not have access to the most sensitive, non-invasive tests.
(e) The ascending complications of bacterial
STIs have a disproportionate adverse effect upon the health of
women. In the non-pregnant woman, ascending infection causes pelvic
inflammatory disease, increases the risk of ectopic pregnancy,
and tubal damage and infertility commonly ensue. In pregnant women,
infections may cause miscarriage, prematurity, and neonatal death.
Such complications are associated with delayed treatment, which
is more likely in the young, ethnic minorities and other less
privileged sections of society. There is a clear association between
high STI rates and the local health authority deprivation index.
(f) The annual numbers of newly diagnosed
HIV positive have accelerated, especially in women where they
have more than trebled since 1990 (now representing 40 per cent
of the annual total). A substantial proportion of these are women
from high prevalence countries, especially from sub-Saharan Africa.
This places additional burdens on the need for developing acceptable,
appropriate, and culturally competent services.
(g) Co-infection with STIs and HIV is regrettably
common, facilitates their onward transmission, and often causes
treatment difficulties. Up to 50 per cent of homosexual men diagnosed
with infectious syphilis in London are HIV positive. Although
most are previously undiagnosed, there is also concern about continuing
partner change and unsafe sexual behaviour in those who are already
aware of their HIV diagnosis.
(h) In homosexual men, who have a high prevalence
of HIV, alarming increases in STI cases have occurred between
2000 and 2001. Preliminary analyses show that new cases of infectious
syphilis trebled, of gonorrhoea increased by 50 per cent, of chlamydia
and new genital warts each by 72 per cent, and of first episode
genital herpes by 44 per cent.
(i) Co-infection with HIV and tuberculosis,
including multiple drug resistant strains, is becoming more common
in ethnic minorities. Such cases increase workload substantially
and, with the dispersal of asylum seekers, often involves less
experienced or single-handed clinicians with little infrastructure.
(j) New national targets to normalise HIV
testing and increase test uptake will reduce the numbers of individuals
with unrecognised HIV infection but will also add to the expanding
numbers requiring long-term care.
13. Thus, inadequate provision of services
and delays in GU Medicine clinic access are exacerbating inequalities
in sexual health and jeopardising clinical governance requirements.
14. Many clinics throughout the UK have
experienced rapid increases in HIV workload, especially in migrant
workers and asylum seekers, many of whom do not have English as
their first language. This has often occurred without any increase
in the staffing or infrastructure needed to provide good clinical
care for a group of patients with complex needs whilst still maintaining
open-access provision of sexual health services.
15. Some districts still have no GU Medicine
service provision and rely upon patients' ability to travel considerable
distances to clinics in adjacent districts.
16. Many single-handed consultants, especially
those covering more than one district, find themselves unable
to take leave for either continuing professional development or
even annual leave in extreme cases lest their service be left
with unsuitable cover arrangements. Single-handed jobs are unattractive
and recruitment to posts is compromised in less attractive areas.
17. Changes in commissioning arrangements
are exacerbating current problems. Strategic Health Authorities
are not yet up and running and experienced sexual health commissioners
in PCTs are rare. There remains a lack of clarity about specialist
commissioning for HIV and the toolkit for GU/Sexual Health is
not yet available. Not surprisingly, sexual health has fared badly
against other priorities in the annual SAFF bidding process.
18. Although many clinics in the larger
cities and towns are in dedicated premises, there are still many
part-time services that share facilities with other specialities
that are often not involved in sexual health service provision.
To eradicate inequalities in service access, we have strongly
recommended that clinics should be open at least one session each
19. Many services that are being provided
in dedicated facilities are very short of space. Not only are
patient confidentiality and privacy jeopardised but also effective
working of the entire clinical team is compromised. A majority
of clinics do not have adequate facilities either for partners
who wish to attend together or for mothers with small children.
20. Support, including translation services
and social care, especially for recent migrants and asylum seekers,
is becoming increasingly required.
21. IT support in many clinics needs to
be upgraded in order to modernise routine clinical practices,
including electronic filing of laboratory results, and to provide
more relevant disaggregate epidemiological and surveillance data.
Communicable Diseases StrategyGetting Ahead
of the Curve
22. The recently published Chief Medical
Officer's Communicable Diseases Strategy ("Getting Ahead
of the Curve") has again emphasised sexually transmitted
viruses as a priority area. In our response, we have restated
our view that bacterial and viral STIs are inseparable and that
the public health control of all STIs including HIV must continue
to be a priority. We also have commented about the relevance of
STIs and blood borne virus infections to the other infection priority
areas of tuberculosis, hospital acquired infection, and antimicrobial
23. Public Health Laboratories are the mainstay
of routine diagnostic support for GU Medicine clinics in large
parts of England. Proposed changes to the PHLS have raised concerns
about the continued provision of high quality laboratory diagnosis
of STIs, and the wider introduction of new technology to improve
the timeliness of STI detection.
24. GU Medicine clinics provide most of
the surveillance data for STIs to the Communicable Diseases Surveillance
Centre that are the basis for informing the Department of Health
and government about current trends, progress towards national
targets, and the consequent refinement of national strategy. Robust
reporting mechanisms must be maintained. For adequate surveillance,
disaggregate data are required. Although there are pilot sites,
there are no resources set aside for implementing disaggregate
data nationwide. Surveillance of sexually transmitted infections
diagnosed outside of STI services is poor.
25. The national sexual health and HIV strategy
proposes that there should be three levels of care. Levels one
(general sexual health) and two (specialist services) will be
based in primary care and will support the existing level three
(consultant-led specialist care) services that will continue to
lead on the development of clinical protocols, referral pathways,
and local clinical networks.
26. The Royal College of General Practitioners
has made clear that GPs have neither the time nor the training
to take on additional sexual health care provision at present
because of the pressures of other priorities. The introduction
of the sexual health promotion campaign and of chlamydia screening
will inevitably increase patients' demands upon primary care,
and both GP and patient frustrations will increase if specialist
providers are unable to cope with additional referrals in a timely
fashion or provide the necessary support to other providers.
27. Workload pressures are also inhibiting
the contribution of specialists to the education and training
of primary care practitioners, and to further development of local
sexual health networks. This will hinder the enhanced collaborative
working that is necessary if both the teenage pregnancy and sexual
health targets are to be achieved.
28. Surveillance systems across all levels
of service are being discussed by a DH group. However, no resource
is being identified to develop an appropriate surveillance system.
Discussions have moved towards the use of e patient records and
development of the minimum data set to be used by all healthcare
providers identifying sexually transmitted infections. This will
require a considerable amount of work and resource given the problems
of confidentiality. It would be advantageous for sexual health
services to be used as a pilot for developing linked records with
appropriate firewalls to protect confidentiality.
29. Sexually transmitted infections including
HIV have major costs in terms of money but also human costs. HIV
incidence is rising rapidly. These infections affect predominantly
the young sexually active population which are the future of the
30. Delay in treatment of STIs promotes
their onward transmission, the development of expensive complications,
and the spread of HIV.
(a) We are seeking to address the current
dearth of UK information about the costs of treating STIs and
their complications. It is estimated that the cost of treating
pelvic inflammatory disease in the USA is at least $3 billion
(b) The average annual cost of managing HIV
patients in the UK is £15,000. Thus, for the prevalent caseload
of 23,000, the annual treatment costs in 2002-03 can be expected
to be in excess of £345 million, and the cumulative lifetime
costs of prevalent HIV cases by 2007 to be in excess of £5
billion. However, if the growth in annual numbers of newly diagnosed
cases between 2000-07 continues at 15 per cent rather than 10
per cent, these cumulative lifetime costs will be in excess of
(c) In the national strategy document, the
cost benefit of preventing a single HIV case is quoted as being
upwards of £0.5 million. The cost benefit of preventing 2,000
new infections will be at least £1 billion. In 2001, the
annual total of newly diagnosed HIV cases is expected to be over
31. Current service capacity is super-saturated.
The current crisis must be resolved rapidly by immediate strengthening
of GU Medicine services.
32. The national sexual health promotion
and HIV testing campaigns will inevitably increase patient demand.
In Wales, the consequence of the recent national sexual health
promotion campaign was the doubling of GU Medicine clinic appointment
delays from an average of three to six weeks. We have strongly
recommended to the Minister for Public Health and DH that these
national campaigns be delayed until service capacity has been
expanded. Short-term capacity increases may be achieved by increasing
the number of weekly clinic sessions and extending clinic hours
33. Five million pounds recently distributed
among 270 STI clinics will not achieve increased staffing levels
because this is non-recurrent funding. The recent changes in NHS
structures are unhelpful for local negotiation. A recent survey
has shown the following:
54 per cent of PCTs have not agreed
a process for implementing the National Strategy for Sexual Health
61 per cent do not have a completed
assessment of local sexual health and HIV needs.
27 per cent have not so far included
sexual health and HIV in the spending and financial framework.
18 per cent have no appointed lead
for sexual health and HIV.
18 per cent do not have a multi-agency
28 per cent of clinicians were not
able to say who the person responsible for HIV and sexual health
commissioning was for their area.
52 per cent of clinicians have said
that PCTs were not providing adequate funds for their service
to deal with the present crisis.
34. We have emphasised that progress towards
national targets requires the restoration of growth in consultant
numbers and additional health adviser, nursing, and administrative
35. Around 70 doctors will complete their
specialist training in GU Medicine during 2002-03. These could
contribute to the government target of 7,500 new consultant posts
by 2,004 contained in the NHS Plan, and accelerate progress towards
the additional 250 consultants required to achieve the Royal College
of Physicians recommendation of one consultant per 113,000 population.
In each year thereafter until 2007, a further 30-35 additional
specialists will complete their specialist training, of whom one-third
will be required for retirement replacements and the remainder
will be available for consultant expansion.
36. Unless new posts are created, in line
with manpower planning expectations five years ago, some of this
expensively trained resource could be lost away from front-line
patient care in the UK.
37. Targeting new posts to currently single-handed
consultants whilst ensuring that all posts additionally have some
clinical sessions within the nearest inpatient (usually teaching)
centre, will ensure that capacity requirements are improved throughout
England. It will also promote clinical governance, the development
of service networks, contributions to local multidisciplinary
planning teams, outreach work and increased support for training
in primary care.
38. Funding support for continuing professional
development of non-consultant grade doctors in GU Medicine, many
of whom also work in primary care, could make further contributions
to level two service developments and promote linkage of the teenage
pregnancy and sexual health strategies.
39. We also strongly recommend that there
should be incentives for other primary care practitioners to obtain
training in sexual health care, such as in the Sexually Transmitted
Infections Foundation (STIF courses), to support level 1 service
40. Implementation of these proposals would
require around £25-30 million. We are convinced that improved
patient access will reduce onward transmission of STIs and HIV,
will boost service morale, and increase our capacity to meet the
41. There are no vaccines available for
any sexually transmitted infections. Research is being undertaken
for HIV vaccine. Little work is being undertaken in the UK in
vaccines for other sexually transmitted infections. Some funding
has been made available for microbicide research. All these are
long-term solutions and with ever increasing numbers of patients
being infected, resource must be given to provide services.
42. It is important that improvements to
clinic infrastructure also be addressed. The executive summary
of a report "Modernising Genitourinary Medicine Services
in England and Wales" prepared in June 2001 is appended.
43. The cost of the support requested to
increase service capacity and curb the spread and treatment costs
of STIs and HIV is several orders of magnitude less than the inevitable
healthcare costs of delay.