Sexual Health and HIV Strategy: a survey of general practitioners on Teesside and North Yorkshire, England

S.C Tayal, A.A. Opaneye 
Consultant physicians, Department of Genitourinary medicine, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW

Key words: sexual health, general practitioners, policy, access, service provision.

Introduction
The National Sexual Health Strategy was published in July 2001(1,2). The Strategy was in response to unfavourable indices of sexual health in the UK - high number of unwanted teenage pregnancies and high rate of sexually transmitted infections (3,4). The Strategy recommended three levels of services and local implementations are to be encouraged. Since the publication of the strategy, the House of Commons (parliament) select committee on health in their report "found sexual health service to be a shambles" (5). It is important for experts in sexual health matters (GU Physicians, Consultants in Community Gynaecology and Family Planning) to know how they can be of help to primary health care workers, e.g. General Practitioners. It is on this basis that we conducted a survey of general practitioners in Hartlepool, Middlesbrough and Northallerton.

Methods 
During the months of March and April 2003, a semi-structured questionnaire (table 1), comprising eight questions was sent to individual General Practitioners in Hartlepool, Middlesbrough and Northallerton. The population covered on Teesside is about 550,000 while that of north Yorkshire is 116,000. The questions were designed with the help of the Clinical Audit Department of South Tees Hospitals NHS Trust. All the completed questionnaires were sent to the Clinical Audit Department where the data was analysed. The different types of services stipulated in the national strategy are in table 2 and each service is sub-divided into three categories - (table 1).

Results
Three hundred and forty-one (341) GP questionnaires were sent out, asking what services they provide now and what services they would be willing to provide in the future. One hundred and fifteen (33.7 percent) GPs returned the questionnaires and the results are shown in table 3. About fifty-two per cent are providing initial sexual history and risk assessment (level 1) and 27% are testing and treating sexually transmitted infections (level 2). Only 7% are doing invasive STI testing in men (level 2). About 62% do not consider or have facilities to do partner notification and are unable to provide this service. This aspect of service is a major part of managing and controlling sexually transmitted infections. 

Discussion
The present survey of general practitioners indicates that between 9 – 63 % are unable to provide various levels of service. It is however reassuring that a significant proportion of these general practitioners (15-39%) are willing to provide various types of services if given appropriate funds and training (Table 3).
Pressure on the sexual health service has led to unacceptable delays in accessing services (6). Improving sexual health in England will have major benefits for overall health and wellbeing and for NHS resources. There is an urgent need for expansion in the workforce (consultants and non-consultants) to accommodate the workload (7). The NHS provides a comprehensive range of sexual health services – including GUM clinics, community family planning clinics and services in primary care – but often they are fragmented, poorly advertised and too narrowly focused. In many instances, there is poor or no communication between these groups (8). Access is a problem in some parts of the country. In rural areas especially, long journeys and patchy provision often restrict access to services. Information on sexual health is often out of date or simply not available.
The sexual health strategy proposed that there should be three levels of service provision for a comprehensive local service. To achieve this Commissioners and providers in primary care, acute and community Trusts need to work together to set up a network that provides all three levels of service and meets the need of the local population (9). There should also be a mechanism in place to control the quality of service provided. The increases in infections, unplanned pregnancies, and high risk sexual behaviour puts considerable demands on the existing services for STIs and HIV, contraception, abortion, and health promotion. It is however reassuring that a significant proportion of these general practitioners (15-39%) are willing to provide various types of services if given appropriate funds and training (Table 3).
There is a progressive decline in the nation's sexual health resulting in a public health crisis, which can only be resolved by political and financial commitment (10). We believe that this is the time for action as further delays are detrimental to the sexual health of our community.

Comments
Sexual history and risk assessment
Provide service but would prefer to refer to GUM clinic

STI testing for women 
We provide this to some extent but I feel not able to do so fully
Very basic

HIV testing and counselling
On clinical need. If increase in demand will need resourcing

Hepatitis B immunisation 
None occupational
As per national guidelines? Need updating
Occupational

Testing and Treating STI’s 
We provide a service because there is no alternative available
Partly
Confidently in women

Partner notification
Limited facility only
Encourage patients to tell partners to see own GP or STD clinic

Invasive STI testing for men 
In general practice we often end up doing tests for STIs or treating them because patients present to us and the STI clinic facilities are inadequate e.g. patient rings and gets answering machine, surely is against confidentiality issues to leave details on an answering machine?

There appears to be no communication from STI service to help GP and practice nurses on how to manage suspected STI.

These patients should be dealt with by your department (GUM), not GP.

Extra training would be beneficial in all areas

Need faster access to GUM clinic when STD isolated

We do it, but I’m not sure if we do it very well, due to limited experience

We are already grossly overworked and if more is dumped onto us from secondary care we will have to close down – it’s that bad!!!!

We do it but would prefer to refer to GUM clinic

Table 1

Table 2

Table 3

Acknowledgement: The assistance given by the Clinical Audit Department of South Tees Hospitals in the preparation of the questionnaire and analysis of the results is much appreciated.

References
1. Department of Health. The national strategy for sexual health and HIV. London: DOH, 2001
(www.doh.gov.uk/nshs/bettersexualhealth.pdf).
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4. Djuretic T, Catchpole M, Nicoll. Int. J. STD. AIDS 2001; 12: 571-2.
5. House of Commons Select Committee. Report on Sexual Health. June 2003.
6. Tayal A, Opaneye A. Gonorrhoea in pregnancy: time for action. Sexual Health Matters 2003; 4(1): 48-49.
7. Rogstad KE: Medical workforce speciality review for genitourinary medicine 2001-02, England and Wales,
N Ireland, Scotland. Int. J. STD AIDS. 2002; 13: 495-8.
8. Opaneye A. Genital thrush in women: the attitudes and practice patterns of general practitioners on
Teesside and north Yorkshire. Journal of Royal Society of Health 1999; 119 (3): 163-165. 
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Health Matters 2003; 4(1): 3-5.
10. Adler M. Sexual health. Editorial. BMJ 2003; 327: 62-63.

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