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Tackling the Growing Crisis in the UK's Sexual Health Services

Posted on: Sunday, 2 April 2006, 06:00 CDT

By Anonymous

Rising rates of Sexually Transmitted Infections (STIs) are threatening to overwhelm Britain's sexual health services.

The number of new cases of STIs such as chlamydia, syphilis and gonorrhoea has risen dramatically in recent years - rates in the UK have almost trebled in the last decade. There are also currently more HIV patients than ever before. At present, the UK has the worst levels of sexual ill health since the second World War.

Sexual health services are suffering from underinvestment and a lack of expansion and many genito-urinary medicine (GUM) clinics are finding the increased workload unmanageable. A report published on 1st December 2005 by the NHS Confederation and the Terrence Higgins Trust (THT) warned that a radical rethink of the UK's existing sexual health services is urgently needed to tackle this growing crisis.

Since the government published 'Choosing Health',^ the Public Health White Paper for England, there have been announcements of extra funding and a goal that by 2008, everyone referred to a GUM clinic should be offered an appointment within 48 hours. However, clinics are a long way from achieving this goal. There is no doubt that long waiting times for treatment at clinics are increasing the spread of these entirely preventable infections.

The scale of the problem

Recent statistics, including figures published by the Health Protection Agency (HPA) in November 2005, show that the rapid increase in STI rates show no sign of slowing down:

* An 8% increase in the number of chlamydia cases diagnosed means that 103,932 new cases were reported in 2004, and it is now estimated that around 10% of sexually active women are infected.1 Chlamydia can have serious side-effects, including pelvic inflammatory disease, which can lead to infertility. However, the disease is often symptomless and so many women do not come forward to be tested - they often have no idea they are infected.

* A 37% increase in the number of syphilis cases diagnosed means that 2,254 new cases were reported in 2004.2 Although one of the less common STIs in the UK, infectious syphilis rates have leapt by a factor of 15 between 1995 and 2004, including increases among women and heterosexual men. Although the numbers involved are lower than for chlamydia, this is still a worrying trend, as syphilis can have serious health implications and it had been thought for years to be under control in the UK.

* Incidences of gonorrhoea doubled between 1997 and 2003.

Figure 1: Number of new diagnoses of selected STIs at GUM clinics in the UK, 1995 to 2004

* Approximately 7,000 people are newly diagnosed with HIV in the UK each year.3 There are now more people living with HIV than at any time since the epidemic began - more than 58,000 in the UK.

Since 1995, there has been a sustained increase in diagnoses of most STIs in the UK, and some have shown substantial rises (see figure 1).

Factors contributing to these increases include changes in sexual behaviour. Successive surveys by the National Survey of Sexual Attitudes and Lifestyles show that more people are having more sex with more partners - and much of this sexual activity is unprotected. It also shows more people are having sex at a younger age.

Poor awareness among young people is also having an impact. Young people are increasingly unaware of the dangers of unprotected sex and the risks of HIV and STIs are not taken seriously. A recent survey by the Schools Health Education Unit showed that, whereas in 1993 26% of boys aged 12-15 were concerned about HIV, in 2003 only 6.5% of the same age group were concerned. Sex education in UK schools has failed to adequately inform young people of the realities of STIs and HIV, and the emphasis from central government in recent years has focused on teenage pregnancy.

Some groups remain at higher risk of STIs than others. Young people are more vulnerable as they generally have higher numbers of sexual partners, greater numbers of concurrent partners and change partners more often than older age groups. Young women are also biologically more susceptible to some STIs than older women.

Others at disproportionately high risk of STIs include men who have sex with men and people from black and minority ethnic communities. STIs also tend to affect more people who are socioeconomically deprived or those who have poor access to treatment or prevention services.

The increasing pressure on GUM clinics

The cost of this increase in sexual ill health is high, both to those affected and to the NHS. There are more than 1.5 million attendances at GUM clinics in the UK each year, a number that has been growing by at least 15% annually. The extra demand on GUM clinics is leaving many local health services struggling to cope, putting pressure on their ability to deal with infections and leading to much longer waiting times.

The pressure on GUM services was highlighted in a report on sexual health published by the Health Select Committee in 2003, which said: "England is currently witnessing a rapid decline in its sexual health.... Sexual health services appear ill-equipped to deal with the crisis that confronts them. Median waiting times to services are currently around 10-12 days and some services are turning hundreds of people away each week." The report also estimated that between 1991 and 2001, GUM clinic workloads increased by 155% and diagnoses increased by 61%. A survey in the same year found that only one in eight GUM clinicians believed they had enough resources to manage their current workload and more than two-thirds said their ability to provide services was declining.

There is no doubt that delays in access to GUM appointments are fuelling the rise of STIs in the UK. The longer a person remains untreated, the more likely they are to pass the infection on to others. The government is aware of this and has set a target on waiting times for England. All NHS Primary Care Trusts (PCTs) local delivery plans state that by 2008 all patients should be offered an appointment to be seen within 48 hours. However, many local health services are still a long way from achieving this - a review of waiting times in 2005 showed that 74% of people needing routine appointments and 24% of people needing emergency appointments in England were not being seen within the 48 hour target.4

What is being done to improve the situation?

The government set out a variety of measures to tackle sexual ill health in 'Choosing Health'.' The White Paper outlines a commitment to providing new capital and revenue funding to modernise sexual health services, allow better communication with people about the risks and allow the NHS to offer faster and better prevention and treatment.

Pledges were also made to provide efficient and convenient STI screening services through a national programme. Plans to accelerate the introduction of a national screening programme for chlamydia were also highlighted, with the aim of covering the whole of England by March 2007. In addition, the government wants to take steps to introduce and evaluate the effectiveness of chlamydia screening in retail pharmacies. There was also a commitment to reduce the rates of new gonorrhoea diagnoses by 2008.

Protected sex is essential to stop the spread of STI's. Picture supplied by Durex

The White Paper also set a target on waiting times for England. It states that the percentage of patients attending GUM clinics who are offered an appointment to be seen within 48 hours of contacting a service should increase with time and reach 100% by 2008.

In November 2004, UK Health secretary John Reid announced proposals for a 300 million campaign to tackle the problem. "Prevention messages are not getting through", he said, "We need to act now on sexual health - and make it a priority." The funding includes:

* A 50 million advertising campaign to highlight the risks of unsafe and irresponsible sexual behaviour, which will aim to educate young people about the dangers of unsafe sex. This will be the biggest sexual health campaign since 1986.

* 130 million to improve GUM services to ensure that all patients will be seen in GUM clinics within 48 hours by 2008.

* 80 million to ensure the National Chlamydia Screening Programme covers the whole of England by March 2007.

* 40 million for upgrading contraceptive services, including an audit to identify and address the gaps in these services.

A further 15 million of funding was announced in July 2005. This money was intended to enable the NHS to make immediate improvements to buildings and facilities, allowing GUM clinics to expand their services. The funds for frontline sexual health services will be transferred to GUM clinics via their PCTs.

What progress has been made? Appointment waiting times - the 48- hour access target

By 2008, 100% of patients attending GUM clinics should be offered an appointment within 48 hours of contacting a service. The problems associated with longer waiting times have already been outlined above. Unfortunately, progress on this target is not looking very positive.

In October 2005, the THT warned that GUM clinics were falling further and further behind in the 48-hour targets. Its study of the situation suggested waiting lists were fuelling the STI pandemic, \with figures of HIV, syphilis and gonorrhoea soaring while those infected wait for check-ups.

The HPA's review of appointment waiting times in May 2005 demonstrated the difficulties many people face in accessing treatment, with less than half seen within 48 hours. Waiting time figures broken down by region demonstrate the variations in care across the country and the rapid improvements that will be needed before 2008 if the target is to be met. Clinics in the North East have the most progress to make if they are to reach the target by 2008. Almost three-quarters of people in that region are not being offered an appointment within 48 hours. London waiting times are the shortest, with over 60% being seen within the target period. However, that still leaves a long way to go.

In October 2005, the BBC's Panorama programme carried out a survey, reporting that over a quarter of all sexual health clinics in the UK are currently unable to treat patients needing urgent attention within the 48-hour target. Researchers found that 18% of clinics were using restrictive systems, making it more difficult to book an appointment. Waiting times have grown so much that one clinic was taking bookings nine weeks in advance. Some GUM clinics are turning away new patients; most have closed down their walk-in services and others are making it increasingly tough to get an appointment. Some clinics now require people to ring during a narrow time window, making it a fight for appointments for some - other clinics simply refuse to accept new patients.

Reduction in the incidence of gonorrhoea

In contrast, the gonorrhoea target discussed in the White Paper already appears to be having an impact. The numbers of new diagnoses of gonorrhoea were down by 10% between 2003 and 2004 compared to 3% between 2002 and 2003. However, it is vital that work in this area is sustained and effective - without concerted action the incidence of gonorrhoea could easily begin to creep up again.

National Chlamydia Screening Programme

New initiatives such as the National Chlamydia Screening Programme (NCSP) aim to control STIs through early detection and treatment. In particular, the NCSP targets sexually active people who might not normally have been tested for Chlamydia. Since it began in April 2003, the NCSP has increased the number of places offering Chlamydia screening to include more non-GUM health centres. The total number of screens increased from just over 17,000 in the first year to over 63,000 between April 2004 and March 2005. By January 2006, more than 78,000 people had been screened. There are 26 regional programmes in place so far - each locally managed by a Chlamydia Screening Office - covering over 25% of PCTs in England. The scheme has recently been extended to all other areas of England - meaning the government is well ahead of the target to have all Chlamydia Screening Offices operational and offering full coverage across the country by 2007. There will be approximately 80 Chlamydia Screening Offices in England and national screening is due to begin in April 2006.

In another initiative, nearly 6,400 test kits were handed out during December in Boots stores across London in the first month of a pilot aimed to make Chlamydia testing more accessible for people aged 16 to 24. The Department of Health funded pilot offers a free and confidential testing service in over 200 high street Boots pharmacies across London. The pilot will be monitored and evaluated over a 2-year period to test the community pharmacy setting as an alternative access point for chlamydia screening. If successful, the scheme could be rolled out nationally.

The serious problems with current sexual health provision are apparent to staff working in sexual health and the government - not to mention those trying to access services. The prevalence of STIs is continuing to escalate, clinics are struggling to cope and targets are still a long way from being met.

The recent funding has the potential to make a real difference and is viewed by many as the last chance to turn around sexual health services. It could make a massive difference, both to the individual and to public health. It is an opportunity that must be seized immediately.

1. 'Choosing Health: making healthier choices easier'. Public Health White Paper, Department of Health, November 2004.

2. Health Protection Agency data on STI diagnoses, published June 2005.

3. Health Protection Agency data on HIV diagnoses, published February 2005.

4. 'GUM Waiting Times Audit: National, Regional, Residence and Clinic based results', Health Protection Agency, May 2005.

Copyright The Royal Institute of Public Health & Hygiene Spring 2006

Source: Health and Hygiene

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