Limited clinic access - hypothermia

The woman’s legs were shaking uncontrollably as she lay back on the examination couch. The nurse and I exchanged puzzled glances. I began running possible diagnoses through my mind as I reviewed what I knew so far.

It was 9.15 on a routine Friday morning at a genito-urinary medicine (GUM) clinic in mid-January. The woman’s legs were still shaking vigorously and uncontrollably, perhaps from anxiety? She was fully alert, so she was not having seizures. Was it malaria? Septicaemia? 

“Are you feeling okay?” I asked her. “Your legs seem to be shaking a lot.”

“I’m okay, Doc.”

“Has this been happening long?”

“No Doc, just this morning”.

“What time did you get here?”

“Seven this morning – I was second in the queue outside.”

It was still dark outside, very wet and cold: the winter equinox. She was wearing a knee-length skirt and no tights. Images of shivering trekkers flooded into my mind, shivering helplessly in the altitude and cold in my previous year in Nepal.

“Are you feeling cold?” I asked.

“Yes, Doc.”

“Well, you’ve got hypothermia and exposure,” I explained. “I’ve never seen it in a sexual health clinic in England before but I’ve seen it in the Himalayas, where you might expect to see it. But you got hypothermia and exposure queuing for a sexual health check-up in the middle of London in the 21st century.”

The end of walk-in treatment

That was the moment I finally decided I could no longer insist on a walk-in policy in our clinic. For years, the pressure had been building. More and more people waited each morning outside the clinic door before it opened. Queues were getting bigger, starting earlier, snaking around the building, exposed to the elements. Members of the Trust Executive had noticed the queue as they passed it in the morning on the way to their offices.

More and more people were being turned away from the door as the morning quota filled quickly. There were longer waiting times inside the clinic as the staff worked through the patients who had got in. There was more frustration, shorter tempers, shouting and abuse from angry patients. More stress, more staff sickness, more strain all round, resulting in burnout and madness.

None of that had been enough for me to feel that we should end the principle of a walk-in service. The long-suffering London public had, I felt, no right to expect anything else. But exposure and hypothermia developing in a member of the queue made me realise that the current situation was dangerous.

An uncomplaining woman with a sexual health problem had developed a life-threatening complication while queuing up to get her sexual health needs seen to. It was not due to her condition, it was because of the system that was trying to help her. It was demand overwhelming resources; a situation completely out of control.

Booking by phone

Two and a half years later and working conditions are ostensibly much better. There are no queues outside the clinic. People make appointments by phone. We give more telephone results, make fewer follow-up appointments, and have made other innovations to allow more patients to be seen with the limited resources available. But it’s not enough.

The first two men I saw this morning presented with guilt; what we call “post one-off blow-job” symptoms. One night, or rather a few minutes, of casual, drunken fumbled sex in each case; not with each other, by the way. Both of them in regular relationships, both full of regrets. Then there was a young woman with gonorrhoea and another woman with two partners, unknown to each other. A string of people with pelvic pain or penile soreness, worried  adolescents and a new couple wanting a checkup.

“I had real problems getting through on the phone, Doc. It’s taken me weeks to get an appointment. I can’t get through, or it’s booked up,” I’m told by one of the patients. But it’s a familiar message.

Our new system means appointments must be booked by phone and we only book up to 48 hours ahead. We have a “triage” system to pick up the urgent problems that get to us, but no way of determining who gave up trying to get through. We don’t know how many people decide to try elsewhere or go nowhere.

Masking the problem

Many sexual infections are asymptomatic, or the symptoms settle spontaneously. But the infections remain, perhaps causing more serious damage resulting in infertility, chronic pain or further transmission to new partners. People with anxieties around sexual health may be the ones who give up trying to get through. Potentially avoidable minor problems may become deep seated and harder and more costly to treat.

We used to feel the pressure of the unmet needs of the public who were turned away from our doors because they passed it on to us directly. Now it’s more hidden and less obvious, kept at bay by the phone system. Every now and then our phone queuing system breaks down, so that some patient caller, who has moved slowly up the queue to be the next to talk with the receptionist, is suddenly bounced back to the end of the queue, or even cut off.

The atmosphere for staff and patients actually inside the clinic is much better than it used to be; but we have placed a hidden barrier around our services. Most other clinics have done the same. We know that demand has not gone away, and nor have the infections and distress and suffering – indeed, they have increased. We are doing our best, but more resources are needed.

It's about education

Schools are where the work of sexual health clinics should start. There needs to be age-appropriate listening, teaching and learning. All it requires is a bit of realism, courage and commitment from policy makers. Sexual health doesn’t start at the phone line or at the door of the clinic, or in the raging hormonal and social chaos of adolescence – it must start long before then. Otherwise, we will only ever be wondering how to meet the “unmeetable” demands with limited resources.

Supporting data

“Between 1991 and 2001, new episodes seen at GUM clinics in England, Wales and Northern Ireland rose from 669,291 to 1,332,910. Clinic workload increased by 155% and diagnoses by 61%. Between 2000 and 2001 alone the figures for episodes at clinics rose by over 10%.” Health Select Committee report, 2003.

The Royal College of Physicians recommends a ratio of one consultant per 119,000 population. This would require an extra 173 consultants (96% increase) for England. There are currently 274 consultants in England. Some examples of ratios reported by GUM consultants are:

• in South Buckinghamshire it was 1:300,000
• in North Cheshire it was 1:325,000 
• in the North West it was 1:400,000.

Health Select Committee report, 2003

Only one in eight GUM clinicians responding to a recent survey believe they have enough resources to manage their current workload and more than two-thirds say their ability to provide services is getting worse. THT/BHIVA survey, 2003