Please activate Java... ANNUAL REPORT 1997/98

Foreword

This is the second 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 is in the aftermath of the changes that is ongoing in the health services. Primary Commission Groups and Health Investment Plans will now define prioritisation of services. Sexual health service remains under invested. Regrettably the concerns raised in the first annual report were ignored with continuing increase in the incidence of sexually transmitted diseases - notably gonorrhoea and chlamydia.

The Bure Clinic website was sponsored and commissioned on the 3rd July 1998 by the Great Yarmouth Haven Rotary Club. The impact of sexual health education and healthy sexual behaviour will hopefully become manifest over the ensuing period.

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

The recently published white paper A First Class Service: Quality in the New NHS, placed great emphasis on improving and maintaining quality and on clinical governance, which it described as " a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish".

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 siting 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

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. Hepatitis B immunisation programme for "at risk patients"
9. Provision of inpatient care to HIV/AIDS patients
10. Provision of care to patients admitted with sexually transmitted infections in other wards in the hospital
11. 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 knows 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

In this annual report we have concentrated on total new patient attendance. In 1998 we had a growth of 5.5% increase in attendance compared to 1997 and 1996. In 1996 and 1997 there was only an increase of 2.8 and 2.5% respectively.

Table 1(in the annexe) shows a breakdown of the annual attendance since the clinic relocated to its present site in 1991. 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.

Fulfilling all aspects of the Monk's report, particularly responsiveness in seeing patients within 2 working days will need investment in medical workforce. Improvements in response were noted when additional medical cover was available in the Bure Clinic. We have recently submitted for publication our audit of responsiveness poignantly reflecting these shortfalls.

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.

1997/98 was characterised by curtailing the level of activity to reflect the reduced medical workforce (see annexe). Specialist clinics operative from 1st July 1996 allowed qualitative care by streamlining patients into needed care facilities. However, some specialist clinics have had to be discontinued in 1997/98. This includes the vulval clinic and referral of inflammatory smears to the Bure Clinic. The KC60 reflects these activities as shown in the annexe.

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. The trend was maintained in 1998.

Chlamydia trachomatis also increased 2 fold from 1995 to 1996, and that increase was sustained in 1997 and 1998. Nationally a 12% rise was seen in the incidence of chlamydia. The increase seen in the Bure Clinic is a function of more case detection in the district as more women are now screened, prompting referral for contact tracing and partner notification.

The increases seen are 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. This rise is still sustained in 1998 with an increase of 10.4%.

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. In 1998 the reported numbers remain the same.

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. There were two cases of statutory venereal infection seen during this period.

The Vulval clinics run with a Consultant Dermatologist has now been discontinued. We intend in the next financial year to re-establish the service after a formal service development plan. The Colposcopy Service in the Bure Clinic has been under utilised, because of insufficient 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. In 1998 we participated in the expanded access of the Du Pont (Efavirenz) a non-nucleoside analogue for the use of patients failing on triple therapy. 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. However this has not been sustained in 1997/98. Virological failures were manifest despite HAART (highly active antiretroviral therapy), including side effects of these potent regimes.

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 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. Harry TC, Cozens C. Outcome of inflammatory smears in women seen in the Bure Clinic. Int J STD AIDS 1998; 9: 299-300.
4. Partner notification and provider referral differences across the Atlantic. Presented at the MSSVD Spring meeting in Athens. May 1998
5. Participation in Dupont Pharma DMP 266 (Sustiva) Expanded Access Programme-Europe 1998.
6. Patient-led survey evaluating responsiveness of the service. Harry TC. Quality and resource management in GUM service delivery. Int J STD AIDS (in press)

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 Infect. 1998; 74: 231.
Harry TC. Sexual ill-health among blacks in the UK. Lancet 1998; 351:1363-4
Harry TC. Sexually transmitted diseases. Lancet 1998; 352:650
Harry TC, Snobl H. Website as a tool for patient education in sexually transmitted diseases. Int J STD AIDS 1998; 9: 779-8

  Total clinic workload

In this annual report we have concentrated on total new patient attendance. In 1998 we had a growth of 5.5% increase in attendance compared to 1997 and 1996. In 1996 and 1997 there was only an increase of 2.8 and 2.5% respectively.

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 2535 in 1995 to 2941 in 1997 and 3103 in 1998. The relevant aspects are that with increase in the numbers of patients attending so also, the complexity, diversity and the STD related problems. These have led to significant increase in 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 same remained for 1997/98.

Gonorrhoea

The incidences of gonorrhoea remain sustained in 1997/98 respectively. There was a four-fold increase from 1995 to 1996 in the Bure Clinic (see annexe). 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. This level of prevalence is still maintained in Great Yarmouth & Waveney. In 1997/98 there were 2 cases of gonorrhoea as a result of presumed child sex abuse.

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. In 1998 a slight decrease was seen which is not of any statistical significance. 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 we have launched our website, to supplement sexual health education among adolescents in our catchment population, as 30% 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 prioritization of this patient group due to shortage of medical manpower. The number seen we hope will be different in the next report as we have now increased our medical manpower albeit temporarily.

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. An audit is ongoing in analysing the viral types and determining correlation to recurrence.

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. We have now discontinued routine culture in women.

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 antibody tests carried out amongst 106 females age range 15 - 53 years and 116 males aged 19 - 65 years.

In 1997 there were 282 HIV antibody tests done on 135 females aged 15 - 66 years and 147 males aged 12 - 61 years.

In 1998 there were 380 HIV antibody tests carried out amongst 177 females aged 13-60 years and 203 males aged 15-74 years.

Total cohort of HIV positive patients for this period was 21. The cumulative total incidence in our local population is (0.016%) or 17 per 100,000 population amongst those aged 15 - 64.

The risk categories of the present cohort are 38% homosexual/bisexual, 23% heterosexually acquired of which - 9.5% acquired from sub-Saharan Africa, 11% intravenous drug use and 28% was a combination of bisexuality and in some undetermined.

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. In 1998, 38 cases of minor and 3 cases of major cervical 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. In 1998 only 21 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.

In 1997/98, the reduced numbers is still reflective of the reduced threshold in colposcoping females with genital warts as a sole criterion.

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 counselling has also meant additional workload.

An HIV Community based Clinical Care co-ordinator for the Waveney Area was appointed in 1997. The Health Advisor now only oversees the community needs of Great Yarmouth area. Only two new cases were seen in 1998. Disease progression was seen in.

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 is now being more structured.

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. Now schools are visited, and our website used as self-centred sexual health education tool. 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 recognising that many parents are still mystified about the concept of sex education to their adolescent kids.

In the 1998/99 financial year we would be appointing a second part-time Health Advisor.

Paul Nicholls
Health Advisor

Business Managers Report.

Within the last year, of 1998 / 1999, significant and sustained pressure has been maintained on the services provided for patients accessing Genito - Urinary Medicine though the Bure Clinic at the James Paget Healthcare NHS Trust. Whilst very significant uplifts in the actual numbers of patients may not have been indicated the evidence suggests increasing multi-pathological presentations, and the increased demands on interventional time from the multi-disciplinary team base, has had a significant effect on those providing the service. Resolvement of such issues is never simple. However within this financial year progress has been made, albeit initially on a temporary basis, to increase the medical staff compliment within the Bure Clinic and some funding has been secured to establish a part-time Health Advisor.

Sustaining prolonged interest on Genito-Urinary Medicine has perhaps never been a simple task. Retaining interest, within local health communities within the last financial year has continued to be a challenging occupation. Whilst national and local health care agenda's have remained dominated with the demands of emergency care, reducing waits for elective surgery and improving cancer services, local sexual health has continued to give significant cause for concern within at least some areas of the local health community.

Will this situation be changing in the future? Only one factor remains certain and that appears to be that sexual health will continue to deteriorate as society continues to be dominated by a strengthened sexual culture. This deterioration in sexual health will continue almost unaffected by any challenging message that continues to be too gently imparted to a vibrant and vigorous community. Having been involved with the multi-disciplinary team within the Bure Clinic it is apparent that there is no lack of desire to change, to challenge, to confront and to strengthen this message. However confronted by successive tides of sexual ill health, each apparently rising higher than the last, it is apparent that those providing the tidal defences will soon feel overwhelmed.

The achievements of the last financial year must be built upon. The strategy that is to be adopted within the Bure Clinic has three significant objectives:

1) To promote the status of sexual health on the agenda's of the local health care communities.
2) To review the provision of current services and to ensure that these are managed in the most effective manner possible to achieve maximum impact and effect.
3) To establish defined areas for development within the service and to seek resources to initiate these developments for the next financial year.

The team from the Bure Clinic, used to being challenged by service demands, will have a changed influence in 1999 / 2000, as the service will be challenging itself and others to support an agenda of change in a more pro-active and invigorated manner. With this achieved those providing the service will be supported in providing quality outcomes for their often-silent community of patients, which they will continue to serve.

Andrew Fox
Medical Services Manager
April 1999

Sisters report.

The last two years have shown an increase in workload involving new and rebook patients. 1996-97 saw a growth of 2.8% and 1997-98 a 5.8% growth. There has been some commensurate funded increase in clinical hours, but not in nursing and secretarial cover.
My concern is that if this increase in workload is sustained, the extra pressure on the nursing and secretarial staff will take its toll.
If we are to pursue the process of setting up an evening clinic, the nursing and secretarial cover will have to be reviewed.
The commencement of the Multi-Disciplinary meeting prior to the Monday morning HIV Clinic has proved very useful in providing updated information for all the nursing staff.

Sue Davies
Sister in Charge.

Quality Standard Indicators
Recommendations of the Monks Report 1988

- 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)
- In accordance with the recommendation of the Venereal Disease regulations, arrangements should be made for some evening clinic sessions to be held after 5pm
- Twenty minutes consultation recommended to the Department of Health by the Royal College of Physicians on the advice of the GUM Committee.
- 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.
- 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 1999/2000

- Creation of a middle-grade post.

- Increase additional nursing support.

- Increase additional secretarial support.