STIS IN NON-SPECIALIST SETTINGS

STIs in non-specialist
settings: general issues
Sheila Kinghorn

The prevalence of STIs is increasing in the UK and GUM clinics

are struggling to cope. The National Strategy for Sexual Health in
England1 highlighted the need for additional primary care-based
Level 1 and Level 2 services, but the new General Medical Services
(GMS) GP contract contains no special provision for sexual health
and there are no Quality and Outcomes Framework points as an
incentive. More GPs are now to be encouraged to develop special
interests in sexual health, and Enhanced Services are to be commissioned to support specialist care.2

GP contract
The new GMS contract encompasses the following Essential
Services:
initial advice about sexual health promotion and STIs
referral for specialist sexual health services, including tests for
STIs
advice on and referral of unplanned pregnancy.
Contraceptive advice and treatment are Additional Services (except
fitting IUDs, which is an Enhanced Service).

Whats new ?
The role of primary care in sexual health has increased
A new GMS contract for GPs has been introduced
Additional Quality and Outcomes Framework points for
sexual health services are currently under negotiation
Chlamydia screening will achieve national coverage by
2007, after universal adoption of molecular testing on
urine samples or self-taken vaginal swabs

Sheila Kinghorn is Senior Partner in the Moss Valley Medical Practice,

Eckington, UK, a Trainer with the Chesterfield Vocational Training
Scheme, and GP Tutor at the University of Sheffield. She qualified from
the University of Sheffield. She is a member of the North Derbyshire
Sexual Health Strategy Committee. Conflicts of interest: none.

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2005 The Medicine Publishing Company Ltd

STIS IN NON-SPECIALIST SETTINGS

The new General Medical Services GP contract

Limitations of Essential Services

Under the new GMS contract, points are gained for having
a 10-minute consultation time (previously, the average was
7 minutes). Unravelling a sexual health problem in that time
is difficult. The GP must take the history, examine the patient,
complete laboratory forms, label specimens and formulate a management plan. There may be difficulties in accessing a nurse or
chaperone. Another important concern is negotiating a means of
contact should the patients results prove positive. During this first
consultation, there is often a need for pregnancy testing, emergency
contraception, planning for future contraception, issuing condoms
and education. Further discussion is required before testing for
blood-borne viruses.
Short-cuts can be taken by avoiding examination at this stage
and undertaking initial testing for Chlamydia on urine samples
or a self-taken vaginal swab, if nucleic acid amplification testing
is available, and arranging a follow-up appointment for further
discussion and examination. However, teenagers, in particular,
may miss follow-up appointments.

Practices must provide Essential Services (care for the sick and
those with chronic diseases)
Practices are expected to provide Additional Services such
as cervical screening, basic contraception, immunization and
maternity care
Health and Social Service Boards must also commission a
range of Direct Enhanced Services such as improved access,
influenza immunization and minor surgery
National Enhanced Services are commissioned to provide, for
example anticoagulant monitoring, fitting of IUDs, minor injury
services and intrapartum care
Local Enhanced Services may be commissioned by Primary
Care Organisations to target health needs in particular areas

Quality and Outcomes Framework points

As part of the GP contract, a new framework sets out clinical and
organizational standards. Practices will be rewarded for reaching
these standards. The system depends on a high level of data
collection and monitoring.

Referral to the GUM clinic

Because of these constraints on primary care, many patients are
referred to the local GUM service. Other patients may choose
to self-refer because of embarrassment or fear of breach of
confidentiality. With GUM clinic waiting times extending into
weeks, the development of new Local Enhanced Services in
Sexual Health should be an urgent imperative for Primary Care
Trusts (PCTs).

The future
With most GPs already over-stretched by trying to achieve quality
points under the new contract, it will be surprising if many agree
to take on the extra burden of time-consuming training outside
the practice plus the additional workload. The Government has
announced a further 300 million to be channelled into sexual
health,4 and it remains to be seen how much will reach primary
care for the development of these services.

Local Enhanced Services

Department of Health guidance on effective commissioning of
sexual health and HIV services3 suggests that GPs, after appropriate
training, could provide more specialized services to augment those
given by the hospital. Training would necessitate completion of
the Sexually Transmitted Infections Foundation Course and having
the Diploma of the Faculty of Family Planning (or equivalent training). Attendance at GUM clinics and training in the insertion of
IUDs/subdermal implants would also be necessary. Competency
would be assessed and regular updates at consultant-led clinics
essential.
These specially trained GPs will be able to support specialist
services by testing for and treating many STIs, and providing comprehensive contraceptive care, hepatitis B vaccination, pregnancy
testing and referral for termination of pregnancy. Payment for this
service is under negotiation with local PCTs. GPs who agree to
see patients from other practices would be offered extra financial
inducements.

REFERENCES
1 National strategy for sexual health and HIV. London: Department of
Health, 2001.
2 Choosing health: making healthier choices easier. London:
Department of Health, 2004.
3 Effective commissioning of sexual health and HIV services. London:
Department of Health, 2003.
4 Press release. London: Department of Health, 2004.

Partner notification
A GP working under a Local Enhanced Service will face problems
with partner notification and treatment. It is to be hoped that PCTs
will also commission community-based health advisers to assist.
Patients will have to be reassured that confidentiality remains
paramount, but without contact-tracing the spread of STIs will
continue unchecked.

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2005 The Medicine Publishing Company Ltd