This content was originally published on the MEDFASH website as an e-feature on 10th March 2016 and it is reproduced here with kind permission of MEDFASH.
Dr Melissa Gardner is a GP in London with a keen interest in medical education and sexual health. She is also clinical and educational lead for the SHIP (Sexual Health in Practice) programme run by MEDFASH in several parts of London. In this month’s eFeature Melissa looks at the ongoing opportunities in general practice to provide proactive sexual healthcare to patients as well as the common barriers (relating to patients, clinicians and practices) that often mean these remain untapped. She considers the impact of peer-led training programmes like SHIP and is confident that with the right support practices can provide an excellent frontline service which addresses the sexual health needs of the vast number of patients coming through their doors every day.
GPs aren’t strangers to troubles that lurk under the surface: anxiety, depression, the stress of being an unpaid carer or single parent, domestic violence, female genital mutilation (FGM), debt worries... Uncovering hidden agendas is embedded in our training. GP trainees very quickly learn to always ‘ICE’ patients to pass their clinical assessments; that is, to find out patients’ Ideas, Concerns and Expectations, and work out why they are ‘really’ coming to see you. Your patient has a headache, but what do they want? Painkillers, a shoulder to cry on, reassurance it’s not cancer, someone to ask about violence at home, a sick note..?
We're very used to the fact that issues patients bring to consultations are not necessarily what you end up spending the time discussing. Just this week a man’s medication review quickly turned into a concerned disclosure about his son’s emotional turmoil; and a seemingly simple consultation about vaginal thrush (remember to ask about sugar binges!) led to the patient’s tearful disclosure of her suicidal thoughts. It can be a relief when someone just wants to discuss their knee pain and only their knee pain!
Sexual health issues are often hidden too, so why are GPs not better at addressing these?
Unlike some other concealed issues, when there is a sexual health risk the patient is often unaware of this too. Sexual health may translate as ‘related to things down below’ when in fact genital complaints are common in those with no apparent sexual health risk. Conversely sexually transmitted infections (STIs) can be asymptomatic, or often don't affect the genitals (remember the sore throat, widespread rash and enlarged lymph nodes of HIV seroconversion) and have far wider impact on health and wellbeing than patients realise. This means that clinicians need to be ready to be proactive about bringing up the topic and asking about sexual health risk; not perhaps traditionally the domain of your cuddly family doctor.
Another challenge is the spectrum of sexual health risk seen in primary care. Green et al (2012) looked at female students aged under 27 years in London: as expected, the greater the number of sexual partners they reported, the more likely they were to have attended a genitourinary medicine (GUM) clinic in the last year (10% in those with 0-1 partner, and 30% in those with 4 or more partners). However, across the board 79% of female students in all categories had attended their general practice in the past year. We know that people at high risk of STI or unwanted pregnancy attend general practice. We are just as likely as GUM clinics to see people at high risk, but how visible they are (amongst all those with low or no sexual health risk) depends on us as clinicians.
Sexual Health in Practice (SHIP) is a quality improvement intervention. It is specifically designed to improve sexual health in primary care using evidence-based education during half-day training sessions for GPs and Practice Nurses, supported by a range of clinical and patient resources.
The barriers to providing good quality sexual healthcare in general practice are numerous, but not insurmountable. They are often an interplay of factors relating to the patient (eg fear of diagnosis and what this means), clinician (eg uncertainty about relevant symptoms/conditions) and systems (eg reception staff not aware the practice provides HIV or viral hepatitis testing). The SHIP programme is designed to help clinicians and other team members address these multifactorial barriers. In one teaching session, participants come up with a list of barriers to offering HIV tests in their own practice and we usually run out of space on the flipchart paper. Common barriers participants cite are lack of time; lack of knowledge regarding related symptoms and conditions; difficulties bringing up the subject; and difficulties asking certain questions for fear of appearing judgemental or intrusive.
After over ten years of supporting practices in Birmingham, where the majority of practices now have SHIP trained staff, the programme has more recently been commissioned and rolled out in several parts of London. MEDFASH has delivered SHIP training in the London boroughs of Bexley, Camden, Enfield, Haringey, Islington, Lambeth, Southwark and Lewisham. The programme prides itself on providing advice that is evidence-based and grounded in the realities of the general practice setting: how to bring up sexual health when your patient isn’t expecting it; how to carry out quick (ie GP-friendly) yet thorough sexual health risk assessments; communication strategies; practical tips to increase STI, HIV and viral hepatitis testing in your practice; and how clinicians can be proactive in the assessment of contraceptive need – and their teams supportive of a response.
SHIP works so well because it is designed, reviewed and delivered by peers. Where GPs may cynically shake their heads at an HIV consultant advising them to test for HIV in patients with sore throats, hearing this same message from a fellow GP has a different impact. Oh, other GPs are doing this? How are they managing that? Does it work? Hmm... Knowledge (and experience) of the clinical context is vital for the teaching and advice to be taken on board by participants.
And SHIP has an evidence base itself. Pre-course and 3 month post-course questionnaires of practice nurses showed increased confidence assessing sexual health risk and more time reported for taking sexual health histories (Mullineux et al, 2008). HIV testing rates and diagnoses by GP practices significantly increased after SHIP training was introduced in the London borough of Haringey (Pillay et al, 2012). It’s particularly noteworthy that SHIP demonstrates change in clinical behaviour and patient outcomes (Level 5 of Kirkpatrick’s educational hierarchy) in a field where other educational interventions often have little or no evidence regarding hard outcomes.
So is sexual health relevant to primary care? Yes! There are on-going untapped opportunities in general practice to improve sexual healthcare. We’re based in the heart of communities and carried out over 370 million consultations last year in England alone (RCGP, 2015). We see people with unknown or unmet needs day in, day out – it's just a question of working out how to identify them. We provide 80% of contraception in the UK, a solid foundation from which to link ‘sperms and germs.’ We have other opportunities aplenty in which to bring up sexual health routinely: travel clinics, cervical screening and new patient health checks. In general practice we are used to recalling patients, carrying out health promotion and thinking holistically about our patients – ways of operating that suit the challenges of sexual healthcare.
General practice should aspire to providing excellent sexual healthcare because of where we are, what we do already and how we are used to operating. With the right training we can educate and motivate clinicians to use their skills to bring up, ask about and address sexual health needs in the millions of people streaming through our clinic doors every day. And, as has been proven, we are MORE likely to feel we have time to do this – not less – once we have accessed appropriate and effective training such as that offered by the SHIP programme.
- GREEN, R., KERRY, S. R., REID, F., HAY, P. E., KERRY, S. M., AGHAIZU, A. & OAKESHOTT, P. 2012. Where do sexually active female London students go to access healthcare? Evidence from the POPI (Prevention of Pelvic Infection) chlamydia screening trial. Sexually Transmitted Infections, 88, 382-38
- KIRKPATRICK, D. 1967. Evaluation of training. Training and development handbook. London: McGraw-Hill.
- MULLINEUX, J. F., V.; MATTHEWS, P.; IRESON, R. 2008. Innovative Sexual health education for general practice: an evaluation of the Sexual Health in Practice (SHIP) scheme. Education for primary care, 19, 397-407
- PILLAY, T. D., MULLINEUX, J., SMITH, C. J. & MATTHEWS, P. 2013. Unlocking the potential: longitudinal audit finds multifaceted education for general practice increases HIV testing and diagnosis. Sexually Transmitted Infections, 89, 191-U25.
- RCGP, May 2015: A blueprint for building the new deal for general practice in England, p2