Consultant physicians working with patients - Royal College of ...

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2 Specialties Genitourinary medicineAccess to information, patient support groupsand the role of expert patientInformation on STIs and other areas of sexual health isfreely available through written material and clinicalstaff. Many clinics have websites providing clinicinformation and general information on STIs.Patient support groups and expert patients have been along established and valuable feature of HIV care, but,in the field of STIs, similar support groups and expertpatients are notable by their rarity and should beencouraged. BASHH has establised a public panel and isproducing patient information leaflets through itsclinical effectiveness group. The Herpes Association andthe Vulval Pain Society provide sources of support andinformation.Availability of clinical records/resultsClinics increasingly provide results by text, email or24-hour telephone lines. GUM outpatient records andcomputer registration are kept separate from generalhospital records for reasons of confidentiality. Access totest results is increasingly linked to service laboratoriesby computer. Tests should be anonymised by codedidentifiers. These systems should be ‘firewalled’ fromusers outside the clinic and laboratories. Access to notesby patients or for medicolegal reasons is as for otherspecialties.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team workingMultidisciplinary work is key to quality service delivery.Nurse-led clinics and nurse practitioners areincreasingly frequent. Health advisers are an importantpart of teams. Close links with microbiologists andvirologists are essential.Many HIV services hold regular multidisciplinary teammeetings which have an important training role.Working with other specialistsMost patients with STIs and allied conditions aremanaged within the clinics. Relationships with otherservices include obstetrics and gynaecology, urology,pathology, family planning and psychology. Close linkswith the Health Protection Agency (HPA) have beenforgedoverrecentyearsandhaveyieldedbenefitsinepidemiological surveillance and the targeting of healthpromotion.HIV patients require integrated care and collaborationbetween primary and secondary care and communityhealth services. National standards have recommendedthe development of clinical networks to manage HIVinfection. 2Working with GPs and GPs with a specialinterest (GPwSIs)Sexual health has been identified as a priority for thedevelopment of GPwSIs. GUM has many GPs who dosessional work and are ideally placed to take onenhanced roles in primary care. The specialty iscommitted to working closely with the Royal College ofGeneral Practitioners (RCGP) and commissioningorganisations to provide training programmes andclinical governance for these GPs.Other specialty activity beyond local servicesMany services have set up outreach clinics includingprimary healthcare settings and prisons. Mostconsultants take a leading role in local sexual health andHIV clinical networks.5 Delivering a high-quality serviceStandards that cover all aspects of management of STIs,including the diagnosis and treatment of individualsand the public health role of infection control, werepublished by BASHH in 2010. 3Characteristics of a high-quality serviceFor STIs All patients should be offered an appointmentwithin 48 hours of contacting the service. Patients with a suspected acute STI should be seenon the day that they present. Clinics should be in good quality, easily accessiblepremises. Interviewing rooms and examinationrooms should afford privacy. 4 Management includes taking a general and sexualhistory, a physical examination and collection ofappropriate specimens. Patients should be offered achaperone in line with General Medical Council(GMC) guidance. Clinical examination is supported by immediatemicroscopy of samples, requiring staff to be trainedand monitored in their practice of microscopy. Patients often have multiple infections. STIs may beasymptomatic, and for that reason patients areoffered screening for other common conditions.C○ Royal College of Physicians 2013 113
Consultant physicians working with patients Provision of free treatment for STIs is a legalrequirement. Patients with STIs are advised on the need to notifysexual partners at risk of infection and offeredcounselling on sexual health in general. They areoffered leaflets to support verbal information andfree condoms. Most clinics provide generalcontraceptive advice; some provide emergency androutine contraception methods. Follow-up appointments are required to assessresolution of symptoms and compliance withmedication, to undertake tests of cure, to ensure thatpartners have been notified and to offer furthersexual health advice if required. Enhanced confidentiality for all patients is set out instatute and must be guaranteed by all members ofstaff. All patients presenting to GUM clinics are offeredscreening for HIV infection.For HIV infection Standards for NHS HIV services recommend theestablishment of clinical networks. At the first visit, a full history is taken and a physicalexamination, including STI screen, is performed.Investigations include viral load and CD4lymphocytes, and those for clinical or laboratoryevidence of current or past comorbidity. Patients require regular monitoring ofimmunological and virological parameters andcommencement on HAART as needed. When complications occur, outpatient or inpatientcare with appropriate staff and facilities forinvestigations and management are required. Longer appointment times are required for HIVpatients than those with STI.Maintaining and improving the quality of careLeadership role and development of the serviceRecent strategy documents have emphasised the needfor more community-based care, and that standardsshould be set for this. Any service development musttake into account the individual, and the impact onpublic health. The enhanced awareness and anticipatedcase finding will increase patient attendance at clinics.Adequate resources are the main requirement forimproved patient care.The principal aim is for patients suspecting an STI to beseen on the day that they present or when the clinic isnext open. It is to be determined whether this is bestprovided by open access or a flexible appointmentsystem. Evening and weekend working depends onadequate resources and contractual agreement. Staffskill mix and multidisciplinary working requiresconsideration but an overall increase in workforce isnecessary to increase capacity.Improved laboratory diagnosis, such as nucleic acidamplification tests, are under continualimplementation. Implicit in these developments is theneed to produce timely reports, entailing cooperationwithin trusts between laboratories and clinics, and morewidely between the HPA and trusts.Services should have agreed written guidance for allaspects of management to improve and maintainquality and maximise risk avoidance andmanagement.Education and trainingMost teaching is carried out by NHS consultants inoutpatient clinics and on undergraduate andpostgraduate courses. The paucity of teaching time inGUM in most undergraduate courses is of concern.More academic posts would enhance the capacity forteaching. With the development and delivery of STIfoundation courses, BASHH has a critical function inthe delivery of sexual health education tonon-specialists.Mentoring and appraisal of medical and otherprofessional staffConsultants should be regarded as the team leader forclinical matters for medical, nursing and health advisingstaff of all grades. All staff should have annual appraisaland personal development planning.Continuing professional developmentSpecialist GUM providers play a key role in supportingthe delivery of education, training and governanceacross the range of providers within a sexual healtheconomy and as such maintenance of CPD is essential.This is supported by BASHH scientific and CPDmeetings, regionally and nationally throughoutthe year.Clinical governanceGUM services are central to local networks of STIservice providers, and essential for setting the clinicalgovernance framework, for care pathways and forproviding training to other services in the network.114 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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