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2 Specialties Genitourinary medicineClinical governance is overseen by BASHH’s clinicalgovernance committee.ResearchThe establishment of special interest groups in GUM byBASHH has promoted the research agenda of thespecialty. In HIV medicine, academic posts have beencritical to clinical and basic research. Continued clinicaland scientific research into STIs and HIV is essentialand many clinics work closely with the MedicalResearch Council (MRC), industry and other partners.Local management dutiesEach GUM service providing diagnostic and therapeuticservices for STI and HIV should be led by those holdinga Certificate of Completion of Training (CCT), orequivalent, in GUM. As a multidisciplinary team, theday-to-day management leadership should devolve to alead GUM consultant; he or she would have amanagerial relationship to the general managementstructure of the provider trust.Regional and national workMany GUM specialists participate in regional andnational work, for the RCP, BASHH and local deaneries,in addition to working closely with agencies such as theHPA on public health matters.Specialty and national guidelinesSpecialist guidelines for STIs were first published in1999. The updated guidelines include other areas ofpractice and are available at www.bashh.org. 5Guidelines for HIV management and treatment arepublished by the British HIV Association (BHIVA).The National Institute for Health and Care Excellence(NICE) guidelines include: public health intervention guidance on theprevention of sexually transmitted infections andreduction of under-18 conceptions generic and specific interventions to supportattitude and behaviour change at population andcommunity levels increasing the uptake of HIV testing to reduceundiagnosed infection and prevent transmissionamong black African communities living in England(NICE 2011) increasing the uptake of HIV testing among menwho have sex with men (NICE 2011).Specialty and national auditConsultants review the notes of patients to monitorquality of care and ensure that accurate diagnoses areentered on workload and epidemiological returns madeto trusts and the HPA on behalf of the DH.In 2003, BASHH established a national audit groupwhich undertakes an annual national audit. Specialtyspecificstandards have been developed and arerecommended as an integral part of the revalidationprocess. There are national HIV audits through BASHHand BHIVA programmes.The British Co-operative Clinical Group, a specialinterest group of BASHH, conducts regular nationalsurveys and publishes the results of clinic practices.6 Clinical work of consultantsHow a consultant works in this specialtyInpatient workThe GUM service may require inpatient accessfor the management of complex infections (such asHIV-related complications). A range of inpatientspecialties may require access to clinical opinion fromGUM consultants, who should be available to giveopinion to colleagues on request. GUM physicians whoact as sole consultant for inpatients should have currentknowledge of HIV/AIDS medicine to an acceptablelevel. Levels of junior medical staffing should besufficient to support GUM admissions.Ward rounds vary according to the numbers of patients.Many district general hospitals (DGHs) have only oneor two GUM/HIV inpatients at any one time.Consultants in DGHs may be single-handed withminimal supporting staff and manage most/all of thecare themselves. Alternatively, inpatient care may beshared with colleagues in other disciplines such asinfection or thoracic medicine. Larger units have severalGUM consultants, some of whom specialise in themanagement of HIV/AIDS, with either dedicated orshared junior staff.Outpatient workMost work in the specialty is outpatient based.STI clinics. In a 4-hour session, consultants shouldallow 3.5 hours for their own patients and 0.5 hour forconsultation, teaching and training. Clinical teachingforms a major part of the workload in teaching andnon-teaching hospitals. Fewer patients will be seenwhile teaching but numbers vary according to casemixand supporting staff. Adequate time must be allowed toC○ Royal College of Physicians 2013 115
Consultant physicians working with patientspractise to a satisfactory standard, especially forconsultants working single-handedly.HIV clinics. Where dedicated HIV clinics are held,other healthcare professionals should be availableincluding pharmacists, dietitians and clinicalpsychologists. Education on therapy and adherenceare essential elements of specialised support for patients.Other specialist clinics. Consultants may undertakeother clinics depending on casemix and localrequirements. Many offer consultant specialist clinics,eg for psychosexual problems and erectile dysfunction,and clinical problem clinics, eg for pelvic pain. Theserequire nursing support. Some services providemultidisciplinary clinics such as those for genital, skinor vulval disorders. These clinics provide opportunitiesfor teaching and training.Therapeutic procedure clinicsGenital warts are common and persistent and may betreated in dedicated sessions. Nurses working to patientgroup directives may provide treatment. Intravenousinfusions and inhalation therapy are provided asrequired.Specialist advice on callAccess to GUM/HIVopinion out of hours should be available. Coverarrangements should be appropriate to local need, maybe provided on a network basis and should be explicit.This includes advice on HIV post-exposure prophylaxis,support for A&E departments, inpatients andsometimes problems in the community. Many servicesprovide a consultant on call. With the aid of junior staff,some emergencies may be managed over the telephone.Other specialist activity including activitiesbeyond the local servicesMany services have set up outreach clinics including inprimary healthcare settings and prisons.Clinically related administrationCorrespondence with primary care and other medicalcolleagues is routine. Writing reports for social services,asylum seekers and medicolegal reports is a significantworkload.7 Opportunities for integrated careThe reorganisation of commissioning provides anopportunity for integration of sexual health serviceswhich could lead to significant cost savings through:streamlining management structures; facilitating theprovision of community-based clinics, providing up tolevel 2 STI and contraception care; strengthening thechlamydia screening programme through coordinatedcontact tracing and a seamless pathway into specialistservices; and giving assurance that care is beingprovided to a consistently high standard, irrespectiveof point of access.8 Workforce requirements forthe specialtyWorkloadThe number of sexual health screens (SHS) conductedin GUM have approximately doubled in the last 8 yearsfrom 633,289 in 2003 to 1,258,952 in 2011. There hasbeen a 1.5-fold increase in the number of HIV testsconducted in GUM during the same period from400,166 in 2003 to 1,007,847 in 2011. Among HIVcases, 73,400 are now under care and these increaseannually. Service provision is changing with consultantsrequired to supervise staff – both nursing and specialtydoctors managing less complex cases – while seeingmore complex patients themselves.Current workforce numbersThere is a headcount of 396 (approximately345 whole-time equivalent (WTE)) consultants in theUK of whom 54% are male, from the RCP 2011 censusdata 6 (England, 364; Wales, 12; Northern Ireland, 5;and Scotland, 15). Of those consultants under 40 and 35years of age, 80% and 90% respectively are female. Fromavailable data, 51% of female consultants work less than10 programmed activities (PAs) compared with 7.3% ofmen. This is an important consideration for workforceplanning where many consultants are likely to want topractise part time at least for a proportion of their career.The rate of expansion has decreased to 1% in 2011and this contraction is likely to continue in the presentfinancial climate despite an increasing workload. Thereis likely to be a future reduction in numbers of highertrainees as part of cost savings irrespective of workforceplanning. Ninety (24%) consultants are over 55 years ofage with a further 84 (22.6%) aged between 50 and 54.Number of consultant programmed activitiesrequired to provide a specialist service to apopulation of 250,000The figures below assume 40% of consultations will beundertaken by consultants. Patients will also be seen byother staff, including doctors in training, specialty116 C○ Royal College of Physicians 2013
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The Royal College of PhysiciansThe
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AcknowledgementsWe would like to th
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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1 Physicians in the NHS todaycan be
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2 Specialties Cardiovascular medici
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2 Specialties Clinical geneticsClin
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2 Specialties Clinical geneticsPati
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2 Specialties Clinical genetics6 Cl
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2 Specialties Medical ophthalmology
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2 Specialties Metabolic medicineMet
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2 Specialties Metabolic medicineof
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2 Specialties Palliative medicinePa
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2 Specialties Renal medicineRenal m
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2 Specialties Renal medicineLocal a
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2 Specialties Renal medicineInvolve
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2 Specialties Renal medicineAcademi
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2 Specialties Renal medicineTable 1
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2 Specialties Renal medicinekidney
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