1999 Annual Report

This third annual report is in the aftermath of the changes that is ongoing in the health services. Continuing Professional Development and Accreditation with peer-review are the dominant issues. Concerns raised about inequity in service provision has now been rectified temporarily with the appointment of a part-time four sessions a week Consultant currently filled by Dr H. Sims The Bure Clinic website sponsored and commissioned on the 3^rd July 1998 by the Great Yarmouth Haven Rotary Club received an excellent review in the General Practitioner. Sexual health education and healthy sexual behaviour is the dominant theme for 1999/2000.

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

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

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

1. Comprehensive screening and treatment for sexually transmissible infections.
2. Partner notification and provider referral
3. HIV antibody tests with pre and post test counseling
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 immunization 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

In this annual report we have concentrated on total new patient attendance. There was an increase of 3.4% attendance of new/re-registered patients in 1999. 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 annex) 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 appointment of the 4 sessional consultant posts has created a continuum of high quality consultant-based service.

We now see all patients within 2 working days of requesting an appointment is consonance with the recommendations of the Monk's report.

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.

1998/99 was characterized by maintaining specialist clinic services in tandem with maintaining consultant based mixed clinics.

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 continued in 1998 and 1999 respectively. There were 44 cases in 1999, representing an increase of 37.5% over 1998 figures (see annex)

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%. In 1999 there was an increase of 19% in new cases.

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. In 1999, there was an increase of 5% in new cases.

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 in 1998. In 1999 we had only one case of gonorrheal infection isolated from the eyes of an 8 year-old boy. The source remains a mystery.

The Vulval clinic run jointly with a Consultant Dermatologist has now been discontinued. We have not been able to re-establish the service.

The Colposcopy Service in the Bure Clinic remains under-utilized, because of reduced cervical cytology screening undertaken in the clinic.

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 11^th 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.

In 1999 we were able to procure Phase IV medications, Glaxo-Welcome (Amprenavir & Abacavir). We enrolled a pregnant mother in RCOG Cohort of AZT use in pregnancy to reduce maternal reduction. Baby remains uninfected 18 months after delivery. Disease progression from treatment failure occurred in 2 patient in this period. We now routinely utilize viral resistance assay and therapeutic drug level monitoring when necessary.

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 prophylaxis to healthcare workers exposed to HIV infection is led from the department in collaboration with the Occupational Health department, Accident & Emergency and Ward 17. The Department of Health guideline for routine screening for HIV and Hepatitis B in pregnancy will be implemented in the Trust from April 2000. We need to ensure continuity in providing a fully responsive service for all aspects of Genito-urinary Medicine by assuring adequate staffing level, a mandate for the Organisation.

Research & Audit publications 1996 - 99

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 23^rd - 26^th 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 open label safety study of Efavirenz (DMP 89421 Sustiva) non-nucleoside analogue in patients failing on therapy.

6. Patient-led survey evaluating responsiveness of the service. Harry TC. Quality and resource management in GUM service delivery. Int J STD AIDS 2000; 11: 751-4.

7. Audit on the impact of pre-test HIV counseling upon knowledge about HIV and the motivation to change behaviour. Presented as a poster at the 4^th International Conference on the Biopsychosocial Aspects of HIV Infection, Ottawa, Canada 15^th -18^th July 1999.

8. Evaluation of sexual health knowledge of adolescents in a Great Yarmouth High School. Presented as a poster at the 6^th World Congress, Sun City, South Africa 21^st - 24^th November 1999.

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, Snobl H. Website as a tool for patient education in sexually transmitted diseases. Int J STD AIDS 1998; 9: 779-8

Harry TC. Information Technology for postgraduate education. Br J Obstet Gynaecol 2000; 107: 144

Harry TC. Sexual health knowledge of adolescents in a Great Yarmouth High School. Int J STD AIDS 2000; 11: 129-31

Harry TC, Matthews M, Salvary I. Indinavir use: Associated reversible hair loss and mood disturbance. Int J STD AIDS 2000; 11: 474-6

Total clinic workload

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. There was an increase of 3.4% attendance of new/re-registered patients in 1999 from 2215 to 2290 cases.

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, 3103 in 1998 and 3107 in 1999. 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 2 cases of syphilis seen in 1999 in our clinic. They were in 2 men who declared themselves homosexuals. The index had secondary syphilis with a co-existing peri-anal herpes simplex infection probably acquired in London from an itinerant partner . The contact had a primary syphilitic chancre on presentation.

Gonorrhoea

The incidences of gonorrhoea remain sustained in 1998/99 respectively. There was a four-fold increase from 1995 to 1996 in the Bure Clinic (see annex). 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 1999 there were 51 cases of gonorrhoea including epidemiological treatment, the greatest rise seen in the district. There were 44 cases of gonorrhoea confirmed by culture. Great Yarmouth has the highest incidence of teenage pregnancy in the region, a surrogate marker for unsafe sex.

In east Norfolk, Great Yarmouth has the highest unemployment rate and deprivation index which is manifested in the sexual ill health markers of high teenage pregnancy and gonorrheal infections.

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. In 1999 this has increased to 160 cases. 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. In 1999 there was a 4% rise noted in new diagnosed cases. From 205 cases in 1998 to 209 cases in 1999.

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. 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. In 1998, we had 53 cases. In 1999, an increase of 19% in culture positive cases was noted (63 cases).

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. In 1999 there were 266 cases.

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 counseling 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.

In 1999 there were 351 HIV antibody tests carried out amongst 177 females aged 14 – 55 and 174 males aged 16 – 61 years. Of the males 5 declared themselves homosexual.

Total cohort of HIV positive patients in 1999 was 20. 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 32% homosexual/bisexual, 64% heterosexually acquired of which - 9.5% acquired from sub-Saharan Africa, & Thailand, 4% intravenous drug use and a combination of bisexuality and undetermined cause.

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. In 1999, we had 7 cases of minor and 3 cases of major cervical abnormalities seen. This reduction may be attributable to changes in the guidelines for cervical cytology screening, and the increased threshold for routine screening in the community.

In 1995, 66 colposcopies were performed whereas in 1996 only 26 colposcopies were performed. In 1997 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.

August 1999 saw the addition of a second Health Advisor to the Bure Clinic team. Although only part-time, Alison Jennings’ appointment has not only allowed myself to attend regularly important planning and funding meetings such as the HIV Prevention Working Group, but has also allowed the clinic to adopt a new pro active model with regards to contact tracing and clinical home visiting of our HIV positive clients. Previously, community work and meeting attendance was limited due to the workload within the clinic

CONTACT TRACING RATES

The benefits to the clinic of a second Health Adviser have been proved. (See table) My concern is with the increase of Gonorrhoea and Chlamydia in the district and nationally and the constant stream of asylum seekers through the town, increasing the local population, the currently funded 20 hours a week of a second Health Adviser may prove to be inadequate.

Business Managers Report.

The financial year of 1999/2000 has had to see many areas within the National Health Service consolidate on earlier achievements. Within the Bure Clinic at the James Paget Healthcare NHS Trust, this task has been approached with maturity and awareness that the attention of the public, media, politicians and those commissioning services, remains concentrated on meeting more high profile agendas. This is against the continued background of life within a locality where sexual health continues to deteriorate driven by the domination of an ever-increasing sexual culture. The focus for the organisation and local health systems on emergency care/waiting lists/cancer continues to distract from the broader service issues, which are essential to holistic care within a whole system health economy.

The Multidisciplinary Team within the Bure Clinic has continued to develop services and this has been enabled throughout 1999/2000 by the additional 4 consultant sessions, resourced as a result of the organization's ‘Star Chamber’ process and recognition of the workload demands and deteriorating waiting lists previously experienced within 1998/99 and earlier. At the same time, the support of Norfolk Health Authority in the funding of a part time Health Advisor post has allowed the service to continue to develop themes of innovative practice and individual patient support. Both commitments are recognized as having been extremely positive in the support of quality holistic care for the patient population served by the Bure Clinic, however, it should also be noted that these same developments emphasize an increase in workload on the nursing establishment within this area where additional funding to support this service has not been obtained.

As with many smaller specialist areas, the Medical Directorate has to continue in its efforts to ensure that services such as those of Genito-Urinary Medicine are placed firmly on the organisational and local health system agenda. As processes mature, such as the development of local health improvement plans, opportunities will arise to promote the necessity of what areas such as the Bure Clinic can achieve given time, resource and support. Concerns about local deterioration in sexual health have continued, and remain as a significant challenge for those looking to halt their progress. Whilst the developments that have occurred thus far mean that the service has not been overwhelmed, it is certainly not possible to say that the service is yet able to do more than defend its position and hold its ground, let alone fight back.

Future emphasis, within 2000 / 2001, on issues such as health education, positive promotion of sexual health and broadening the awareness of the availability of Genito-Urinary Medicine services, will help make up further lost ground in the future. However, these are initiatives, which can only occur if a recurring commitment is made to ensure that the developments of the last 12 months become part of a strong foundation for local Genito-Urinary Medicine service provision and not a fleeting response to a service-facing crisis. The team from the Bure Clinic will continue to provide a quality service, on behalf of their patient group, and on behalf of the many people within the local health system who don’t yet recognize that they will be accessing these services at some time, perhaps in the not too distant future!

SISTERS REPORT

The last year has seen Dr. Sims join our team. We are very happy to have him working with us, as no doubt are the patients because we are now able to offer appointments on the same day or within twenty-four hours in a working week. This helps to achieve an optimum service.

We have been unable to recruit a suitable Bank Nurse, after considerable effort! Nurse and Secretarial hours were not increased in tandem with the Clinical and Health Advising hours. I am still hoping that monies may be forthcoming to enable us to advertise for extra establishment hours.

Looking to the year ahead and the challenges it may present: -

The high level of teenage pregnancies causes particular concern. I feel the way forward is education, or as our revered leader, Mr. Blair would say, “Education, Education, Education.”

We are looking at ways we can take the Genito-Urinary Medicine message out to the Community, particularly to those at most risk. A large gap has been left since Health Promotion moved from the James Paget. We often got involved with the team in promoting education sessions and open days etc. I feel that we must attempt to forge closer links with Health Promotion in Norwich, but this is not as easy as having an accessible team in this area.

Whilst the National focus is centred on teenage pregnancies, we must not loose sight of the very strong possibility of the transmission of infection in this group. Therefore the work of the department in the diagnosing and treatment of these infections, and the education, and Health Promotion that goes with this is vitally important.

This can only be achieved with an adequately staffed department, thus facilitating easy access for the patient.

Quality Standard Indicators

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 30^th July 1986 to Regional General Managers)

2. In accordance with the recommendation of the Monks report, arrangements should be made for some evening clinic sessions to be held after 5pm

3. Twenty minutes consultation for new patients recommended by the Royal College of Physicians.

4. Ensure adequate staffing level of Health Advisors to provide their traditional role of contact tracing, partner notification, provider referral, pre and post test counseling 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

Summary of Contents

Foreword