Foreword

This is the first annual report collated in this format since the clinic was commissioned in its present site, having been formally opened in 1991 by Dr R.N.T. Thin, Advisor to the CMO on Genitourinary Medicine & Consultant in GU Medicine, St Thomas' Hospital, London.

This annual report has coincided with the rapid changes the NHS is undergoing in its 50th anniversary and the "Green Paper" on health, with strong emphasis on health investment plans in collaboration with the local community and other providers. The focus being on local response to prevalent conditions collectively identified as areas of prioritisation.

The Bure Clinic serves the catchment population of Great Yarmouth and Waveney Districts over an area of approximately 30 miles by 15 miles. Those aged 15 - 65 years number 122,007 (1991 census). The Towns of Great Yarmouth and Lowestoft 10miles apart are seaports and seaside resorts with seasonal increases in population during the holiday periods. The seaport recently in decline still thrives with seafarers from the world over passing through, although the majority is fishing vessels from Europe.

The annual report will identify epidemiological trends warranting adequate response from participants in the Health Investment Plans of the catchment population.

Sexually transmitted diseases are notoriously hard to control. It is hoped that sufficient information will be provided to encourage healthy sexual behaviours and empowerment for advocacy.

In order to properly fulfil it's role the Bure Clinic will work within Regional and National guidelines, adopt strategies that are in line with good practice and be sensitive and responsive to locally defined needs.

Resources

Staffing:

1 Full time Consultant
6 Clinical assistant sessions (3 unfilled in 1997)
1 Full time sister - G grade
1 Full time Health Advisor - G grade
2.13 W.T.E Nurses - E grade
2.07 W.T.E Secretarial and Reception staff - Grade 4
Sessional Social Worker, Dietician and Clinical Psychologist
Bank nurses for holiday and sickness cover.
Total departmental budget £283,122 including staff pay and non-staff expenditures.

Department profile:

The sitting of the clinic and the standard of accommodation confirms to the Monks Report recommendations. There are dedicated facilities for counselling and treatment. The department is clearly signposted from all patients' entrances to the hospital.

Categories of referral

1. Self referral
2. Referred by contact
3. Health advisor initiated referrals
4. Referrals from GP's
5. Referrals from other Consultants/Department
6. Transferred from other GUM departments

Clinic Access Times

APPOINTMENT SYSTEM

1. General clinics

2. Specialist clinics

SERVICES PROVIDED BY THE BURE CLINIC

1. Comprehensive screening and treatment for sexually transmissible infections.
2. Partner notification and provider referral
3. HIV antibody tests with pre and post test counselling
4. Clinical, virological and immunological monitoring of HIV antibody positive/AIDS patients.
5. Support for HIV positive patients, family and friends
6. Sexual Health Education for patients schools medical and paramedical staff and other agencies.
7. Comprehensive colposcopy service
8. Vulval Clinic jointly provided with a Consultant Dermatologist
9. Hepatitis B immunisation programme for "at risk patients"
10. Provision of inpatient care to HIV/AIDS patients
11. Provision of care to patients admitted with sexually transmitted infections in other wards in the hospital
12. Collaborative research with other agencies involved in the enhancement of sexual health

The Bure Clinic philosophy statement

· The department believes that the patients' confidentiality is of the utmost importance and is assured by the Venereal Disease Act.
· Morality of the patient will never be questioned and to achieve this a holistic approach is adopted in treatment with full patient participation.
· The department is run on democratic principles.
· Opinions and suggestions are welcomed and encouraged from both service providers and patients in adopting best practice
· All staff know they have an important role to play and they are aware of their responsibilities.
· We assure patients of their rights and encourage a civic discharge of their responsibilities.

Trends in attendance & summary

The figure on the left shows a breakdown of the annual attendance since the clinic relocated to its present site in 1991. There was an increase of 11% in the total attendance in 1996 as compared to the previous year in 1995. The 1996 attendance's has been the largest since the clinic was established. This increase was in part due to client responsiveness from our open access service and continuing confidence in the quality care provided. The bereavement of the previous incumbent consultant in October 1995 left a gap in continuity that was redressed with my appointment in July 1996. The marked fall noted in 1997 was due to unfilled clinical assistant vacancies, with the consequence of reduced clinic lists and build up of waiting list.

Whereas in 1995 a departmental audit showed 95% of patients being seen within 2 working days in conformance with the Monk's report recommendation, (there was a full compliment of medical staff), we had a waiting list in excess of 4 to 6 weeks in 1997. A letter was circulated to the Trust and the local GP's regarding these difficulties and it's unacceptability.

The sex ratios continue to be skewed towards more female attendance. This is reassuring as women more acutely feel most of the morbidity associated with STD's.

1996/97 was characterised by an escalating increase in workload and case-mix, in the face of the reduced medical workforce . Specialist clinics operative from 1st July 1996 allowed qualitative care by streamlining patients into needed care facilities. The increase in KC60 reflects these activities as shown in the figure on the right.

The incidence of gonorrhoea increased 4-fold from 1995 to 1996 in the Bure Clinic , and that increase was sustained in 1997, a deviation from the "Health of the Nation" targets.

Chlamydia trachomatis also increased 3 fold from 1995 to 1996, and that increase was sustained in 1997. At the same time we have been unable to maintain open access in conformance with the Monk's Report.

This is of concern, as both infections contribute to significant morbidity and are surrogate markers of unsafe sexual practices.

The fall in incidence of first attack Herpes Simplex has been due to the revised method of recording. Only culture positive cases are recorded after 1995. We have however noted a 14.2% increase between 1996 and 1997.

An initial 18.7 % increase in incidence of first attack genital warts was noted between 1995 and 1996. The decrease of 8.1% between 1996 and 1997 has been due to the waiting list that had built up with the decrease in medical staffing alluded to earlier.
Greater collaboration continues to be fostered with other departments in the hospital and agencies providing sexual health related services. All child sex abuse cases are reviewed jointly with a Consultant Paediatrician. No cases of statutory venereal infection were seen during this period. The Vulval clinics run with a Consultant Dermatologist continue to be oversubscribed. We intend in the next financial year to seek a formal service development plan to meet the increasing demand. The District cervical cytology group intends to formally provide a District Colposcopy Service, incorporating formal referrals to the Bure Clinic to evaluate inflammatory smears.

HIV/AIDS care continues to be multidisciplinary, and led from the Bure Clinic with full participation of the other departments and relevant services. The Bure Clinic was enrolled into the Phase 111b of the Roche (Saquinavir) proteinase inhibitor trial in August 1996, including the Haemophilia cohort following my participation in the 11th World AIDS Conference held in Vancouver. The benefit of triple therapy became manifest early in our cohorts with continual improvement. There has been a substantial reduction in inpatient episodes and disease progression. For the first time we have seen a sharp decrease in mortality in our cohort.

The acceptability of HIV antibody testing within the department continues to increase in momentum, especially for heterosexual males and females. Greater collaboration continues with the Women and Child directorate in seeking to minimise fetomaternal transmission by offering opportunistic HIV antibody testing and providing antiretroviral treatment to those infected. Post exposure prophylasis to healthcare workers exposed to HIV infection is led from the department in collaboration with the Occupational Health department, Accident & Emergency and Ward 17.

We need to ensure that we can provide a fully responsive complete service for all aspects of Genito-urinary Medicine by assuring adequate staffing level, a mandate for both the Organisation and our other colleagues working in the voluntary and statutory sectors.

Research and Audit

1. Participation in the Roche International phase 111b open label safety study of Saquinavir (Ro 31-8959; HIV - proteinase inhibitor) in patients with proven HIV infection.
2. Audit to evaluate "Health of the Nation" target in control of gonorrhoea. This has now been published : Harry TC Are the Health of the Nation's targets attainable. Int J STD AIDS 1998; 9 : 185 - 6.
3. Audit of the outcome of inflammatory smears managed in the Bure Clinic.
Accepted for Oral presentation at the British Colposcopy and Cervical Pathology Meeting, Cheltenham, UK 23rd - 26th April 1998.
Accepted for publication: Harry TC , Cozens C. Outcome of inflammatory smears in women seen in the Bure Clinic. Int J STD AIDS(in press).
4. Audit of the efficacy of partner notification and provider referral in the diagnosis of gonorrhoea and chlamydia trachomatis.
5. Audit of holistic approach in the screening of HIV antibodies in the Bure Clinic.
6. Audit of outcome targets in reduction of Chlamydia trachomatis in the Great Yarmouth & Waveney District.

Other publications:

Harry TC. Management of Genital Chlamydia trachomatis infection. CME BULLETIN STI & HIV 1998; 2 : 4-5
Harry TC, Clark SL. Are race and ethnicity in STD analysis still of relevance? Sex Transm Inf (accepted)

Total clinic workload

In 1996 there was an increase of 11% in the total attendance in comparison with 1995. However the total clinic attendance has remained reasonably stable over the last four years with only limited variations in the actual numbers of new and old patients. What has significantly varied over the last three years has been the increase in the number of KC60 returns, reportable diagnoses which, which have increased from 3041 in 1995 to 5,100 in 1997. The relevant detail of this fact is that whilst the numbers of patients attending has remained constant, the complexity, diversity and the STD related problems have significantly increased the workload of the medical staff .This in turn has increased the resource and manpower demands on supporting diagnostic services.

Syphilis

There were no cases of syphilis seen in 1996/97 in our clinic. The prevalence over the last 7 years is shown.

Gonorrhoea

The incidence of gonorrhoea increased four-fold from 1995 to 1996 in the Bure Clinic (see graph). The national goal was to reduce the incidence of gonorrhoea among men and women aged 15 - 64 by at least 20% in 1995 (from 61 new cases per 100,000 population in 1990 to no more than 49 new cases per 100,000 in 1995). There were 31 cases of gonorrhoea seen in Great Yarmouth & Waveney in 1990. Against a total local population of men and women aged 15- 64 of 122,007, this translates into 25 per 100,000. The expected target reduction by 20% in 1995 would have meant approximately 24 cases. In consonance with national trends for 1995, we achieved a reduction of 93%. We had only 8 cases. In 1996, the total case seen was 31(25 per 100,000). The achieved target was lost and we now have incidence rate of 1990 prevailing. This has been against a background of assumed equitable resource. In 1996 of, 2582 new/re-registered patients comprising 1124 males and 1458 females who attended the clinic, 16 males and 14 females where responsible for 31 episodes of gonorrhoea diagnosed. The mean age of the patients was 26.33 ± 8.05 range 17 - 57 years. The cases of gonorrhoea were uneven over the four quarters as shown in table 1. Peak prevalence was noted in the winter and summer quarters. More cases were diagnosed from Great Yarmouth district than Waveney, reflecting the greater population density in Great Yarmouth district. Whereas blacks notably Afro-Caribbeans have been shown to contribute 15% - 53% of the national gonorrhoea, only 1(3%) female of the 30 patients was of mixed race. Of concern, is the fact that only 75% of the isolates were sensitive to penicillin. All isolates were uniformly resistant to trimethoprim, implying that most patients see their primary care doctor and are treated presumptively for cystitis or urinary tract infection. The auxotype and serotype of the penicillin-resistant isolates suggest 3 distinct strains NR/IB1, NR/IB2 and H/IB. Only one isolate was a beta-lactamase producer acquired heterosexually by a male patient from a casual contact in Bournemouth. Of the 30 patients who attended, 19 (63.3%) contacts were casual and did not attend comparable to the 50% national rate.

Chlamydia trachomatis

The outcome targets of the Association of Genitourinary Medicine Physicians goals and indicators for the management of sexually transmitted diseases guidelines for purchasers of services is to reduce uncomplicated chlamydial infection from GUM Clinics to 100 cases per 100,000 of the population aged 15 - 64 years in 3 years. We have seen a changing paradigm in the incidence of chlamydia over the last 3 years. The prevalence has increased from 3.6% in 1995, 6.8% in 1996 to 8.4% in 1997. In 1995 there were 75 cases per 100,000. This increased to 149 per 100,000 in 1997. This is of concern as during the same period we have seen an increase in the incidence of gonorrhoea. This is one of the reasons for the website, to supplement sexual health education among adolescents in our catchment population, as 40% of all cases of chlamydia in our district is amongst those aged under 20.

Genital warts

Between 1995 and 1996 an in increase of 18.8% of first attack genital warts was noted. The subsequent fall of 8.8% noted between 1996 and 1997 has been due to implementation of a waiting list scenario and reduced clinical prioritisation of this patient group due to shortage of medical manpower.

Herpes simplex infection

The apparent fall in incidence of first attack herpes simplex has been due to a revised method of recording this data after 1995, when only culture positive cases were required to be recorded. Genuine interpretation of this data indicates a 14.2% increase between 1996 and 1997. Viral typing was introduced in April 1997. This will be analysed in the next annual report.

Candidiasis

The attendance has remained stable over the last 7 years. Most women with vaginal discharge and vulval pruritus see their primary care physician or Practice nurse, either of who initiate referral. Most magazines read by women similarly provide advice to patients to attend the clinic, if symptoms of intractable vulval pruritus are discerned. This would also account for the skewed sex ratio in favour of female noted amongst attendants.

Trichomoniasis

The prevalence has remained low with an initial fall and slight rise as shown in the graph in the annex.

HIV antibody test

Although principally done in the Bure Clinic there are a number of other test sites in the district, the local drug rehabilitation centres, the remand and prisons, the renal dialysis centre and the infertility unit. These alternative sites follow the rigid pre and post test counselling inherent in HIV antibody testing.
In the Bure Clinic in 1996 there were 222 HIV tests carried out amongst 106 females age range 15 - 53 years and 116 males aged 19 - 65 years.
Total positive for this period is . The incidence in our local population is 17 per 100,000 (0.016%) population amongst those aged 15 - 64.

Cervical cytology and colposcopy

There were 44 cases of minor and 6 cases of major cytological abnormalities seen in 1995. In 1996, 31 cases of minor and 3 cases of major cervical abnormalities were seen. In 1997, 40 cases of minor and 8 cases of major cervical cytological abnormalities were seen. The fluxes can not all be easily explained, but has been relatively stable.
In 1995, 66 colposcopies were performed whereas in 1996/97 only 26 colposcopies were performed. This reduced numbers of colposcopy performed in 1996/97 was largely due to revised criteria for colposcopy following changes in National Guidelines.

Health Advisor report.

The aim is to see all new and rebooked patients, but this has proved impossible with the workload. On several occasions, patients could not wait to see the Health advisor. The demand of partner notification and provider referral for the noted rise in prevalence of Chlamydia and gonorrhoea, has meant that not all these patients are seen at follow-up visits to evaluate partners who have not attended.

The increase in request for pre and post test counseling, has also meant additional workload.

As there is no HIV Community based Clinical Care co-ordinator for the Great Yarmouth & Waveney Area, the responsibility has fallen on the Health Advisor. The increase in new cases diagnosed, often with their first AIDS defining illness has additional increased the pressures on the Health Advisor.
The relocation of the Health Promotion unit from Great Yarmouth to Norwich has left an unfilled vacuum. The participation of the Health Advisor in the activities of sexual health promotion in concert with other voluntary and statutory agencies in their training and educational programmes has become fragmented with all the other varying demands.

In the past students from local schools and colleges have been invited to the Bure Clinic for sessions on sex education, STD's and HIV. The feed back has been encouraging.
This has been central to the developing of the website to now provide these sessions at the convenience and timing of these pupils.

STD's are difficult public health problem. We would hope parents in concert with us will provide sex education at home assessing our website for the needed information recognizing that many parents are still mystified about the concept of sex education to the adolescent kids.

It is envisaged that a second Health Advisor post will be created and filled in the 1998/99 financial year.

Business Managers Report.

The Bure Clinic has been under considerable pressures over the last two years from inadequate resourcing in manpower, and has therefore not been adequately responsive the needs of the catchment population within the recommendations of the Monks report. The service demands of meeting the needs of HIV positive patients and patients with AIDS has, and will continue to increase the demands on the medical staff. The complexity of patient and treatment management within these patient group places an ever increasing reliance and demand upon the single handed consultant service. Inpatient demands can easily take the consultant away from this pre-dominantly outpatient based service for long periods of time thus compromising service delivery and standards within other areas.

Risks

If this situation remains un-addressed there will be many varying consequences for the future:

1. The local evidence of sexual ill health will continue
2. Sexual ill-health and inequity will become a constant factor in the health make up of the Great Yarmouth and Waveney population
3. Dramatic measures will be required at some time in the medium term to address and start to resolve these issues
4. Health of the Nation targets will remain unattainable
5. The AGUM outcome targets will not be met
6. The Quality standards of the Monks report will remain unattainable
7. The ability of local health care practitioners to achieve quality in service outcomes and delivery will be compromised
8. The longer term effects of sexual ill health will have serious implications for the future potential health needs of the local population, for example rise in inpatients episodes of pelvic inflammatory diseases, epididymo-orchitis and need for infertility therapy
9. The James Paget Healthcare NHS Trust will be forced to develop, and then maintain, a series of measures which will maintain core elements of this service only and these will have to include;
· maintenance of a waiting list for first appointments
· strict limitations on screening and diagnostic support within current resource limitations will have to be set thus maintaining a strictly limited STD screening services
· strict management of wait times for follow-up appointments
· acceptance of limited focus of the health advisor to be able to improve current follow up rates
· concentration of nursing support to provision of basic sexually transmitted disease sessions and withdrawal from extended health promotion practices
· acceptance of increasing waiting lists as long as the situation remains to be neglected
10. The effects of this regime on the sexual health will not lend itself to improving the sexual health profile of the local population. Each delay in treatment extends the potential period in which each patient may put other members of the public at risk. Just as each failure to adequately follow-up index patients sexual contacts creates increased risks of the number of sexual contacts within the local population. The continual increase in the incidence of gonorrhoea and chlamydia only attests to the manifestation of unsafe sexual practices within the community, albeit with all its associated problems viz.;
· increase in teenage pregnancy
· increase in HIV/AIDS
· increase in pelvic inflammatory disease
· increase in ectopic pregnancy
· increase in liver disorders from hepatitis B
· increase in inflammatory smears secondary to STD's
· increase in cervical dysplasia associated with genital warts

Quality Standard Indicators
Recommendations of the Monks Report 1988

1. Any persons presenting with a new clinical problem suggestive of a sexually transmissible disease or who considers him/her self to have been in contact with such a disease should be seen on the day of presentation or failing that on the next occasion the clinic is open(This was recommended by the CMO in his letter of 30th July 1986 to Regional General Managers)
2. In accordance with the recommendation of the venereal disease regulations, arrangements should be made for some evening clinic sessions to be held after 5pm
3. Twenty minutes consultation recommended to the Department of Health by the Royal College of Physicians on the advice of the GUM Committee
4. Ensure adequate staffing level of Health Advisors to provide their traditional role of contact tracing, partner notification, provider referral, pre and post test counselling for HIV antibody test and opportunistic sexual health education to all attendee and the community from sexual health promotion activities with voluntary and statutory bodies
5. Regions should be required to review the distribution of their main GUM services and make improvements where necessary

Recommendations for improvement of Bure Clinic Service delivery in 1998/99

1. Creation of a staff-grade post.
2. Increase in Health Advisory role by creating a second post.
3. Increase additional nursing support.
4. Additional secretarial support.