The importance of striving for greater efficiency

Health care costs are rising in almost every country, not only in real terms but as a percentage of gross domestic product (GDP).¹ In the USA, which has the most expensive health care system, health care now consumes more than 17% of GDP and is rising at double the rate of inflation.¹ If we are to contain or at least moderate the rise in health care costs, then we, the profession, need to become more efficient at what we do.

Improving the efficiency of health care delivery is arguably more important for sexual health medicine than for any other area of medicine. This is because unlike other areas of medicine, failure to provide adequate sexual health care not only affects individuals, but also the community.² History has clearly shown that failure to provide adequately accessible health care services, leads to higher rates of sexually transmissible infections (STI) through prolonging the duration of these infections.² This was well illustrated in the UK, where reduced access to services resulted in large rises in STI prevalence that required substantially more resources to fix, than would have been required if STI rates had not been allowed to rise in the first place.^2,3 Despite the best efforts of the sexual health clinicians in the USA, it seems to have embarked on a program of cost cutting and STI clinic closures that will no doubt increase their already high rates of STIs.⁴

It is important to appreciate that sexual health medicine, perhaps more than other speciality struggles to attract adequate funding for several reasons. First it has no public voice; who for example, is going to write to their local member of parliament and complain that they were unable to be seen or waited too long to have their urethral gonorrhoea treated? Indeed a significant proportion of clinic attendees don’t even use their real names.⁵ Second this area of medicine has the lowest prestige and therefore political leverage of any speciality.⁶ High prestige specialties tend to involve heart or brain, body systems above the belt or treat diseases for which patients are not felt to be morally responsible.⁶ Unfortunately we rank at the bottom and cannot expect to be part of any high profile announcements or political photo opportunities.

For these reasons practitioners in sexual health medicine need to focus on innovation in health care delivery. Several STI services have trialled innovative programs to improve access to STI testing. In the USA, Charlotte Gaydos set up a website where individuals can request STI testing kits (www.iwantthekit.org; verified July 2010).⁷ Over a 4-year period between 2004 and 2008, 3774 kits were requested of which 32.4% were returned. Of these 1203 participants, 64.0% were black, the median age was 23 years, and the chlamydia prevalence was 9.1%. This site is clearly reaching high-risk individuals and terminating disease transmission early. Other internet-based services include a risk assessment program that provides recommendations for STI testing through general practice and sites that assist in partner notification, but there are many other examples.^8–11

Baraitser et al. report in this issue of the Journal on the evaluation of another innovative service where selected clients completed their details on a touch screen and collected their own samples without seeing a doctor or nurse.¹² Support was available from non-clinical staff if required. In a 1-year evaluation of 18 642 clinic attendees, 15% were eligible for self-management and of these, 70% chose the self-management option. Of those choosing self-management, 35% had only had testing for gonorrehoea and chlamydia, 32% collected condoms only and 26% had a pregnancy test only. In this paper they used qualitative interviews and mystery shoppers to evaluate the service. Clients were grateful for the opportunity for the service and preferred the autonomy, privacy and speed that it offers.

The authors also raised some concerns about the service. For example, if a client is seen with a negative pregnancy test result by a clinician there is the opportunity to provide additional advice on contraception at the same visit yet very few of those in this study who tested themselves for pregnancy also obtained condoms or pregnancy advice. It is not known whether they planned to return another day for advice or seek it elsewhere, but it is likely that this advice would be required by some.

The authors do not explain why so few had STI testing undertaken. Given that 71% were 29 years of age or younger, it is unusual that not more than 35% of the 1821 individuals who chose self-management had STI testing. Although the authors do not provide an explanation for this, they do raise the issue that this service may be providing just part of a full STI service and that some may return at a later date for other services. Users did comment that they prefer to self-manage at some times and not others and a choice of a consultation should always be available. This does appear on face value to be a move away from the general recommendation that STI services should provide a one stop shop.¹³

This article illustrates an important point; that some clients clearly want this sort of service and see several advantages in it. It may be possible to include more self-testing through stronger recommendations for STI testing and also to include counselling videos on other aspects of sexual health (e.g. contraception), as these have been used successfully in other areas.^14,15 Other services may also wish to explore the incorporation of serological testing in the self-testing option, particularly among groups if the risk of infection HIV is particularly low.

The authors are to be congratulated for implementing and evaluating and then publishing this information so all STI services can benefit.

None declared.