National Sexual Health & HIV Strategy – RCGP Response
Executive Summary
- The National Sexual Health & HIV Strategy
should be welcomed for what it is - the first attempt to provide
guidance on sexual health matters and HIV infection on a national
basis. It is, however, not without problems and some areas of
deficiency.
- Sexual relationships are for most people a
very positive and normal aspect of their lives and there is a
danger that this will be lost in the drive to reduce morbidity
related to sexual health. This is not a desirable outcome for
anyone.
- It would be helpful to identify other high-risk groups; for
example victims of domestic violence/sexual abuse and
asylum-seekers or refugees – especially those who’s immigration
status is unconfirmed. This latter group is particularly important
since many come from countries which have a high prevalence of HIV
infection and other sexually-transmitted infections
(STIs).
- Because the present strategy has joined
‘sexual health and HIV’ it pays less attention to the needs of
people who use drugs. Little is said about the value of treating
drug users with methadone, the need for hepatitis surveillance (A,
B and C) and the provision of Hepatitis B vaccinations in primary
care. Needle-exchanges form a key role in preventing morbidity
associated with drug-use but are at present under-resourced. The
strategy suggests maintaining needle-exchanges whereas they need to
be increased. The hepatitis C strategy is awaited with anticipation
in 2002.
- The specific regulations affecting GUM and the experience of
these services in dealing with confidentiality tend to inspire
greater confidence in service users. This confidence must
be gained by primary care if fears about lack of confidentiality
are not to serve as an obstacle to primary care provision of sexual
health services. This is especially so in HIV-testing and the
‘Insurance issue’ now needs to be resolved without further delay
for both patients and doctors.
- We are pleased the strategy acknowledges the pressures on GUM
clinics. What it must not do is relieve these pressures by
diverting the patients into primary care as a cheaper option.
Primary care is at present not able to take up this work
effectively. There are real issues of training and resources that
need to be addressed (see action points at end of this document).
Primary Care must receive the support of, and work alongside, good
quality and well-resourced specialist services. If this is absent
then no one gains.
- Complex educational needs lie behind apparently simple level 1
and level 2 type skills and services – for example training needs
to encompass the range of knowledge, skills and attitudes if it is
to be effective, relevant and sustained. It also needs to encompass
team-training and develop some consistency around key subject
areas.
- Finally, we cannot emphasise enough the
great strain of our present and predicted workload in general
practice/primary care. Extra work requires not only new monies but
also manpower resources and time. We are not convinced that this is
adequately addressed within the strategy or from the Secretary of
State.
Back
Introduction to this
response
The National Sexual Health &
HIV Strategy was released in July 2001. This document reflects the
views of the Royal College of GP’s (subject to confirmation). It
has come about through several means: various members of the task
group at the Royal College of GPs have expressed views about the
strategy, there have been informal contacts through the RCGP Sex,
Drugs and HIV Task Group and finally, a consultation day with
primary care on 18th December 2001 was held at the College.
The strategy sets out an important role for primary care and
acknowledges a real role for us in sexual health and HIV. For the
first time the Dept of Health accepts that sexual health and HIV
are major and increasing public health problems and it recognizes
that information has been uncoordinated and poorly available and
there has been poor communication between primary-secondary care
services.
The strategy makes useful suggestions of how to improve the
current situation and proposes developing the role of primary care.
At the RCGP we have welcomed the strategy and its potential but we
are also aware of the training implications.
Importantly, one of the themes of the consultation day and in
many of the other comments was the lack of resources given towards
meeting the aspirations of the strategy (£47.5m for two
years).
These two themes run throughout this response
and are relevant to all sections. Other specific comments and
responses have been categorised into the same chapter headings as
in the original National Sexual Health & HIV
Strategy.
It is clear that sexual health, HIV and
management of drug users have to be addressed with all other
clinical needs in general practice/primary care. Many of us are
aware of multiple pressures on general practice at the present
time. Thus, issues such as limited manpower, including poor
recruitment and retention, down-pressures from primary care
organisations on funding, lack of time, the sensitive nature of the
subject and the low morale within the medical and nursing
professions were articulated as real barriers to implementing the
strategy to its full potential.
The social climate and attitudes to sex
Evidence from other countries in Europe shows the health
benefits of a more open attitude to sex and sexuality, a greater
willingness to discuss sexual matters and to use sexual health
services without stigma (cf the Netherlands). The government
promised in 1999 that its sexual health strategy would aim for a
"more mature attitude to sex". The strategy does little to address
this explicitly, and a lead from government is needed to combat the
stigma associated with sexual health and HIV.
The provision of sex and relationships education for young
people based on evidence of effectiveness is a crucial base on
which to build a more sexually healthy society. Many primary care
professionals agreed that the sexual health strategy
over-medicalised a complex set of problems. Therefore present
teenage pregnancy rates and the rising tide of sexually-transmitted
infections (STIs), especially in the under 20’s, reflect individual
& family needs which require addressing in schools, communities
and homes as well as in surgeries and clinics.
With regard to in-school training the use of innovative
methods such as peer-education should be evaluated in order to
promulgate further messages and information. It was certainly felt
that sexual health had to be marketed (again) – in other words
messages had to be reviewed, repeated and reflected in every-day
life. It is also important to note that, especially in our
multicultural inner cities, cultural sensitivity is essential as
there is evidence that ethnicity is an important influence on
sexual health, STIs and HIV infection.
On this subject it was felt that any strategy
initiative needs to be sensitive and acceptable to certain specific
faith groups especially if they were called upon to work with local
communities in fulfilling its aims. Lastly, we agree that in common
with other comments the national sexual health & HIV strategy
under-emphasises the male partner. Educational initiatives must
involve boys and young men on the basis that infection rates are
extremely high while levels of knowledge are extremely low. More
creative means are needed to ensure that access to health care is
promoted for young men (we acknowledge the recently published
guidance on provision of effective contraception & advice
services by the Teenage Pregnancy Unit).
Better prevention
There is a compelling rationale for continued investment in
health promotion. There is scope for both planned and opportunistic
health promotion interventions by health care professionals, but
such interventions need time and hence additional resources.
Resources are also needed to maintain specialist health
promotion services, which can provide training and advice to
primary care professionals as well as written materials for
patients. The existence of such specialist sexual health and HIV
promotion is threatened by the NHS changes outlined in Shifting the
Balance of Power in the NHS and by the removal of the ring-fenced
HIV-prevention funding. It will be important for the Department to
ensure that mechanisms are in place to ensure the continued
existence of such services, for example through guidance to PCTs on
commissioning and to the new Strategic Health Authorities.
In certain areas asylum-seekers or refugees – especially those
who’s immigration status is unconfirmed – present a challenge to
service-providers because of language barriers and complex social
and psychological needs. This group is particularly important since
many come from countries which have a high prevalence of HIV
infection and other STI’s. Furthermore, this group have problems
accessing GUM services but do attend general practitioners. There
is already evidence that some groups, ie Black Africans present
very late with HIV infection – so late that they benefit less from
combination anti-retroviral therapy.
Better services
Firsts and foremost there is considerable concern that the
Strategy gives responsibility for clinical governance at all Levels
of service provision to Level 3 clinicians. For Primary Care this
is wholly inappropriate as clinical governance structures already
exist through Primary Care Organisations (PCOs). Clinical
governance for Level 1 - and possibly Level 2 - services should
remain within Primary Care. There is considerable support for the
principle that Level 1 services should eventually be offered by all
practices. It should be possible to encompass the new training
requirements for GP Registrars, but only if
a) the issue of clinical governance is addressed, so that
responsibility rests with GP educators and,
b) the SHO review proposals are accepted by the DOH, so that
sufficient flexibility is introduced into Vocational
Training.
Testing for STIs in Primary Care
Chlamydia testing & screening
Chlamydia is clearly important in view of many factors and
primary care should be an integral part of the strategy to reduce
infection rates and complications. However primary care needs the
following:
Information on local needs – this can only be done using
public health – epidemiology – microbiology – general practitioner
– GUM clinic collaboration. The new clinical networks could include
out-reach health advisors employed by the PCT. Family planning
clinics need to be targeted since in some localities they have very
good access to under the 20’s.
- Evidence-based guidelines for STI
treatment in primary care, including chlamydia. Screening in
primary care means actively testing women (and in future men) – are
their resources to deal with this on a nation-wide basis? For
example infrastructure such as supplies of swabs, ‘cold-chain’ (to
and from the laboratories), transport and testing methods. Much of
primary care does not have this currently available.
- Results of pilot-site evaluation studies.
Clinical Governance, general monitoring and community surveillance
all need to be built into this system of screening for chlamydia
infection (for example is there a community equivalent of the
English KC60?). A key point here is that the under 20’s group would
not be ‘captured’ since cervical screening targets are not
activated until aged 25yrs.
HIV
testing
Why is it necessary to re-introduce HIV "counselling"? The DOH
issued guidance on HIV-testing and many have argued this testing
should now be normalised. We in the College firmly believe that
this should revert to HIV-testing and yes, primary care can and do
offer this test. The RCGP task group have developed FiveAlHive a
simple algorithm for the pre-test discussion.
HIV infection and the Insurance Issue. This issue is still
unresolved. The question of insurance is currently a perceived but
real barrier to more widespread HIV testing (and the management of
STIs in primary care) in the community:
- The BMA ‘s advice to practices is that
they should not be answering life-justify">The specific
regulations affecting GUM and the experience of these services in
dealing with confidentiality tend to inspire greater confidence in
service users. This confidence must be gained by primary care if
fears about lack of confidentiality are not to serve as an obstacle
to the provision of sexual health services in this
setting.
- This is not an exclusively HIV/Sexual
Health issue. Genetics is an area which, in future years, may prove
crucial in insurance and life assurance assessments. It is in the
interests of the profession as a whole to develop a sensible,
sustainable approach now.
- A significant number of people are still unaware
of their HIV infection (approximately 1:3 in the UK). Data suggests
that many people in GUM services with a diagnosed STI are not even
offered HIV-testing (see phls data). More testing should be done in
GUM services to provide a lead and give the message that testing
for HIV is ‘good practice’.
Furthermore, it is appropriate to
be testing for HIV infection in other clinical areas -this is
already happening in ante-natal care. There are examples of good
practice, but some non-HIV specialists, especially in primary care
teams, will need resourcing to develop the skills and confidence to
offer testing and deal appropriately with both positive and
negative results. This will include the provision of a culturally
appropriate environment for population groups most affected by HIV
as well as services such as interpreting or advocacy when
needed.
Drug-users
The strategy says nothing on the value of treatment for drug
users such as methadone treatment and the need for hepatitis
screening (A, B and C) and Hepatitis B vaccinations in primary
care. Needle exchanges are an important and accepted aspect of
effective preventive services for this group of patients but are at
present under-resourced. The strategy suggests maintaining needle
exchanges whereas they need to be increased. Currently less than x1
needle and syringe are given out per injector whereas we know the
rate of injecting is at least x2 per day. This does not account for
injectors not yet using current services. If there is no increase
in exchanges, there is evidence that drug-users will start to share
equipment so increasing the risk of Hepatitis B and C.
Where Hepatitis Band C is concerned why no mention of general
practice’s increasing role? Hepatitis B vaccination should be
reimbursed in the same way as other vaccinations. It seems bizarre
that primary care is not supported to provide such an effective
vaccination to high-risk groups.
Abortion Services
There is no target for abortion services – why is this? Could
targets be introduced? For example in Birmingham, a percentage of
abortions are done early and pharmacologically ie rapidly and with
less disruption to all. Why not include this as a pilot projects in
other areas – London and other conurbations.
Additionally there is no mention of private abortion services
which make a significant contribution nationally. Chlamydia and HIV
testing could be offered to this group – already defined as a
higher-risk group for HIV infection and STIs.
General Services
Multiple options for single point patient access is an
excellent idea. While the strategy cites one-stop shops it was felt
that, multiple options may be appropriate; nurse-clinics,
community-based clinics, local ‘well-person’ clinics are ways of
providing similar services.
Currently one significant problem is that information relating
to sexual health is variable depending on the type of service. This
must be standardized and be evidence-based.
The dissemination of key messages to, especially young people,
should utilise modern methods of communication – for example the
internet, web-sites, text-messages as well as more traditional
routes (posters, in waiting-rooms).
Quality and capacity in primary care
There will be a need for adequate numbers and training of
willing GPs and other members of the primary care team, both to
ensure consistent quality of 'level 1' care and adequate numbers
providing 'level 2'. In primary care, where a greater involvement
in sexual health will be expected as a result of the strategy,
standards should provide a framework for education and training, as
well as a tool for commissioning services of consistent
quality.
The already increasing annual diagnoses of STIs, combined with
the strategy’s drive to raise awareness and encourage testing, mean
there is bound to be an increase in workload. This has resource
implications for all services – not just in primary care.
Furthermore, the treatment for STIs is currently free in GUM
services. If treatment is to be routinely provided at level 1 and 2
in primary care in an equitable way, this should also be free of
charge. This has not been adequately addressed in the strategy
except to say ‘pilot projects’ are in place.
The specialist-generalist general practitioner approach has
definite advantages in that it can motivate clinicians in a career
where there is traditionally no further progression, but there is a
need to remember that primary care are specialists in whole person
medicine. In this context developing a public health perspective,
utilising all members of the primary care team and ensuring an
enhanced access to services are the mainstays of the task.
Quality and capacity in GUM Clinics
We are pleased the strategy acknowledges the pressures on GUM
clinics. What it must not do is relieve these pressures by
diverting the patients into an unskilled primary care as a cheaper
option. There are real issues of training within primary care that
need to be addressed. Primary Care must also receive the support
of, and work alongside, good quality and well-resourced specialist
services. If this is absent then no one gains.
Better commissioning
It was felt by many that sexual health would not be
prioritised until it reached National Service Framework-type
status. Until this happened then there will always be inequity
based on a local primary care organisations’ assessment of local
need. This is manifest in many insidious ways:
- Lack of appropriate availability of
condoms and pregnancy-testing in all geographical areas. A real
example of post-code health care.
- The uneven distribution of accessible
‘emergency contraception’ - for example through local
pharmacists.
- Lack of quality of local termination of
pregnancy services.
- Inequality of needle exchanges and drug
treatment services.
There is a need to commission local clinical networks to
develop sexual health networks and fund appropriately, perhaps
using the model developed for drugs and Drug Action Teams.
Supporting change
Professional education and training
- There is a great disparity in the quality
of sexual health care, knowledge, skill and awareness in Primary
Care at present. Well-supported and skilled primary health care
teams may aspire to providing Level 2 services, however we are
aware that others fail to meet the quality of Level 1
services.
- The strategy needs to address the
fundamental gaps in undergraduate and postgraduate medical training
around sexual health issues (including the obvious but often missed
skills of sexual history taking, basic knowledge of STI’s &
blood borne viruses, attitudes towards sex and
lifejustify">Complex educational needs lie behind apparently
simple level 1 and level 2 type skills and services – for example
training needs to encompass the range of knowledge, skills and
attitudes if it is to be effective, relevant and
sustained.
- Confidentiality and anti-discrimination
training and policies are key to implementation of level 1 and 2.
Patients would be more confident they could be assured of
confidentiality especially in the light of insurance issues (see
page 2).
- Despite the numerous courses available to GP’s
and there is a lack of cohesion in planning ‘courses’ to address
the training needs for practices to reach level 1 or 2. Thus
courses such as the STIF (MSSVD- see p46 in Strategy) are not
explicit in their approach to level 1 and level 2 services.
Additionally the team approach to service provision needs to be
matched by appropriate team-training.
Action points
These points arose from the consultation and from other ideas
expressed by various members of the RCGP task group on sexual
health, drugs and HIV infection.
- The sexual health and HIV strategy cannot be
viewed in isolation - there needs to be clearer links with other
health strategies such as the Hepatitis C strategy and also the
Unplanned teenage pregnancy strategy
- Government along with other bodies needs
to clarify the professions’ role in the complex area of sexual
health, including HIV infection and drug-use. The RCGP is keen to
ensure that general practitioners with the primary care team play
their part in prevention, diagnosis and care but acknowledges that
some of these challenges cannot be ameliorated by medicine
alone.
- Additionally if more of this work is going
to occur in primary care mechanisms for data collection is an
absolute essential if future public health trends are to be relied
upon – this issue has yet to be fully addressed.
In order to provide an enhanced Service:
- DoH ought to fund the development of
guidelines for chlamydia screening in primary care and target
younger people (under 20’s) as evidence shows this group to be
particularly vulnerable.
- We need to ensure that prescriptions for
the treatment of STIs in primary care are free of charge - as
contraception currently is for women (otherwise there will be an
obvious discrepancy between GU and GP provision)
- The Red Book (which determines payment to GMS
practices) is being reviewed at present. The RCGP with the DoH aims
to write to the GPC to encourage a sexual health fee, including for
HIV-testing. Unlike present arrangements (FP1001/2/3) it should be
payable for services to men and women and would include sexual
health history taking, screening for chlamydia and other STIs,
Hepatitis B vaccinations and HIV testing where appropriate (see
below). There are opportunities for a similar payment to be
incorporated in PMS.
Extra Resources (are needed
for):
- The development of a national plan for the
distribution of condoms in primary care and pregnancy-testing kits
such that primary care is more responsive to the needs of its
populations. The present iniquitous position is that geography
defines what is available and to whom.
- The development of appropriate data collection
mechanisms and testing for STIs for primary care - this is a key
area which has not been addressed (see page 6 of report).
- The dissemination of the RCGP pre-HIV testing
proforma (pre-test discussion NOT counselling) to all general
practitioners as a practical method of increasing HIV-testing.
Proposed Training Programme
- DoH to support the minimum standards of
care developed for HIV care and being developed for sexual health
in primary care by the RCGP Task Group
- DoH to fund a further day with primary
care in April 2002 at the RCGP to train for level 1 and 2 and
launch the guidelines mentioned above
- DoH to fund the RCGP Task Group, with specialist
input to develop guidelines for the management of STIs in primary
care
Surinder Singh – Sara Madge – Chris
Ford
Sunday, 06 January 2002