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SPECIALIST SEXUAL HEALTH SERVICES: ROLE AND PROVISION
ISSUE 2 APRIL 1999

Preface

The Health Dialogue is an occasional discussion paper published by the Association of Salaried Medical Specialists to stimulate debate and policy discussion on health sector issues. The National President of the Association approves each Health Dialogue prior to publication.

This issue of the Health Dialogue seeks to raise awareness of the problems associated with the delivery of specialist and specialised sexual health services.

The Association would like to thank members and other colleagues working in the field who contributed their time, ideas, knowledge, and editing skills to the production of this Health Dialogue.

Introduction

Despite public health considerations and the financial and social costs of poor sexual health(1), it is difficult to stimulate public debate on the structure of an ideal sexual health service. Patients are unlikely to form pressure groups to highlight funding or resource issues. It has often fallen to health professionals working in sexual health to advocate for change. Their input into government policy has helped to create a service that is co-ordinated and collaborative, notwithstanding the need for some ongoing improvements.

The nature of sexually transmitted infections (STIs) means that people do not always know they are infected. This enables STIs to spread rapidly and sometimes to reach epidemic proportions. Health professionals working in the field believe a dedicated, comprehensive and specialised service is most likely to prevent rapid spread of STIs by their carmonitoring and treatment.

However, recent funding and policy decisions in a fragmented health environment have jeopardised the evolving process of the delivery of this country’s sexual health services, which are comprehensive and span primary, secondary and tertiary care. It is vital that these services are not fragmented further because of disparate funding streams or a funding policy mindset that effectively puts a “Berlin Wall” between primary and secondary sexual health care providers.

Sexual health services in New Zealand require a national framework that will achieve leadership and collaboration among diverse sexual health providers, policy makers and the funder. This paper advocates that the most cost-effective, ideal and integrated method of delivering sexual health care is to retain specialised and specialist sexual health clinics.

In order to achieve cost-effectiveness, accessibility and integration these clinics should be contained within major Hospital and Health Services where specialists and other health professionals specialising in sexual health may provide regional leadership to smaller satellite sexual health clinics, general practitioners and other providers of sexual health care.

Learning from past experiences

The Health Funding Authority presented its financial report to the Health Select Committee on 10 March 1999. In response to a question from the Committee, a Health Funding Authority spokesperson stated the funding was reduced for the Auckland sexual health service clinic because of a policy decision to separate the funding for the service into primary and secondary/tertiary streams. As the funding for self-referrals was reduced, the clinic found itself treating more secondary referrals from other health professionals.

Before the Health Select Committee the Health Funding Authority declared that only GPs and other primary health care providers should treat self-referrals for sexual health. This policy does not acknowledge past experiences or recent literature in the sexual health field. Nor does it acknowledge that some self-referrals to sexual health clinics require secondary and tertiary care.

New Zealand has traditionally had strong public health involvement in sexual health services. In 1917 the Social Hygiene Act directed hospital boards to establish sexually transmitted disease clinics. Section 117 of the Public Health Act 1956 and the Venereal Disease Regulations 1982 required that an individual should be able to “conveniently obtain free treatment at a public hospital or public clinic”. Legislative support for a collaborative sexual health service stems from historical and international obligations. It was also recognised that access to free confidential and specialist services was essential and cost effective for controlling STIs(2).

The hidden nature of STIs does not fit well into the managed care philosophy of the United States (US). The Institute of Medicine found that the US rates of curable STIs are the highest in the developed world. One reason provided by the Institute is the fragmented public and private sexual health services resulting in coverage gaps, inadequate access, and ineffective clinical care. To target all risk groups, they recommend that access to STI-related services be available in multiple settings incorporating both self-referrals and secondary care. They maintain that a safety net provider in the form of dedicated and confidential public STI clinics are necessary for the uninsured, disenfranchised and those who prefer to obtain care from such clinics(3).

Levy(4) summarises a clinical investigation into the closure of a public STI clinic in the District of Columbia. Levy reported that when this clinic was closed there was a marked decrease in reported syphilis cases. The findings from this investigation suggest that clients and their partners may not have received proper diagnostic testing, therapy, and counselling from other sources, if at all.

The sexual health clinics in Perth were restructured into secondary and tertiary care-only facilities in 1994. They disestablished an integrated service by removing self-referrals and the primary care component. In 1995 after this closure there was an increase in the number of STIs in Western Australia(5). This report(5) recognised that by their nature STIs require more open access to services than was being provided at the time by hospital outpatient departments. Following this report, Western Australian sexual health clinics within public hospitals have again broadened their focus to include self-referrals.

Preferred Provider structure

Sexual health professionals advocate that the most cost effective method of providing sexual health services is to have specialised clinics located within Hospital and Health Services. They need to follow a national strategy with consistent funding by a single funder. “The control and prevention of diseases, including STIs, requires a fully informed, and a co-operative rather than competitive, working environment”(6). For this reason and because of the important public health considerations it is vital that sexual health services remain in the public sector, under public sector control.

Despite the high number of self-referrals to a specialist and specialised clinic, it is important to resist the temptation to view a specialised sexual health service simply and narrowly in terms of primary health and secondary/tertiary funding streams. Multiple entry points for patients to access sexual health treatment, inclusive of specialist and specialised sexual health services and other primary health care providers are necessary for prompt diagnosis and treatment, which is a basic strategy for preventing poor sexual health3. Hospital and Health Services provide an environment where there can be multiple entry points to the service and close working relationships between related specialities and primary health care providers.

A specialist service is necessary to support primary care providers because sexual health specialists are required to treat complex contagious disorders that often give rise to complications and difficult case management, for example cancer of the cervix and HIV. Specialists are also important to sexual health services because they:

acquire specialist knowledge in the course of their five year training that is not available to other health practitioners;
can help provide leadership and focus to the overall direction of sexual health services;advise on appropriate quality standards;
provide a supporting role for GPs when it is sought;
provide training;
perform research which may affect public health goals; and
advocate for improvements in service delivery and health policy

Sexual health services, dermatology, gynaecology, contraceptive and fertility services, and urology complement and have a need for one another. Locating a specialised sexual health service in a Hospital and Health Service encourages close co-operation between these services. While these relationships may not have reached their full potential to-date, it is nevertheless a goal that should be fostered by integrated patient funding streams. This may also lead to improved public health and individual benefits.

The ramifications of poor sexual health for public health outcomes and the difficulty for some people to access specialised sexual health clinics(7) indicate that an improved national structure for sexual health services is required. This paper proposes that providing specialist and specialised sexual health services should include the following:

specialised equipment to provide tests that are rapid, accurate, non-invasive, and user-friendly;
shared care ambulatory HIV medicine;
counselling services for those with psychosexual problems, or a history of sexual abuse;
specialist expertise in providing adolescent services – this age group is at risk as they test and challenge the boundaries of what is acceptable, possible or desirable;
specialist anogenital-dermatology services and pre-cancer screening and treatment including colposcopy and vulvoscopy;
services for marginalised groups, e.g. men who have sex with men, sex industry workers, immigrants and refugees;
a referral service for other specialists and community health providers; and
public education outreach services, for example peer education, and Education Resource.

Given that New Zealand’s population is scattered and often geographically isolated, it would not be appropriate to have sexual health services staffed by specialists available in sparsely populated areas. Specialist clinics should be located in major Health and Hospital Services such as Auckland, Hamilton, Wellington, Christchurch and Dunedin. These specialised clinics will be staffed by specialist personnel who may provide regional leadership to smaller satellite sexual health clinics, general practitioners and other sexual health care providers.

In an environment where there is high mobility within New Zealand, increasing rates of immigration and international travel, national co-ordination of sexual health services is essential to achieve optimum disease control.

In order to meet an individual’s needs and to protect the community a free, dedicated and specialised service should be available, particularly because lower socio-economic groups are found to have a higher incidence of poor sexual health(8). The best organisation to provide this is a specialised comprehensive clinic located within a Hospital and Health Service because Hospital and Health Services already co-ordinate services to achieve public, community and personal health goals. There should however, always be a basic sexual health service in smaller centres with easy access to free facilities for the detection and treatment of those with STIs and for contact tracing.

Contact tracing / partner notification

Partner notification or contact tracing seeks to identify and treat all potentially infected sexual partner(s). This is to prevent re-infection of the index case and to prevent the STI from spreading further within the community. Partner notification consists of advising the patient to tell their partner(s) to seek testing and appropriate treatment. It should also involve careful history taking to identify all potentially infected partners, advice on who to notify and follow-up to ensure adherence.

Where patients are complex, recalcitrant or difficult, all health care providers should have an option to refer these patients to a dedicated and specialised contact tracing service for partner notification. Such a service is an important function that any specialised sexual health clinic should be able to offer to other health providers who seek it.

Research, training and education

Public health considerations and the nature of STIs require a specialised sexual health clinic to maintain high quality research and training to standards determined by the appropriate specialist colleges and professional bodies. A specialised and specialist service located within a major Hospital and Health Service provides the necessary facilities for training sexual health doctors and nurses, medical and nursing students, family planning doctors and nurses, student health service doctors, general practitioners and practice nurses across a number of inter-related specialities.

It is important that suitable clinical experience at a specialist level is maintained in order to provide the appropriate research, direction and guidance for the ongoing development and improvement of sexual health in New Zealand.

Funding

Current policy and funding levels constrain the opportunities to expand services to improve access levels and provide a cost effective nationally integrated service. Despite funding restrictions, sexual health clinics have always worked together across the country to conduct contact tracing and to integrate disease control.

The funding restrictions imposed by the Health Funding Authority create a fundamental tension between the long-term goals of specialists to prevent STIs and the short-term financial focus of many Hospital and Health Services. To continue developing the sexual health service, specialists have an important ongoing role to advocate for improvements in service delivery and health policy, discuss potential problems and raise awareness of sexual health service issues. Maintaining separate sexual health service budgets within the Health Funding Authority and Hospital and Health Services would resolve some of these issues.

The Health Funding Authority limits the provision of funding to sexual health services in three ways. First, the Health Funding Authority service specifications are inconsistent throughout New Zealand. Some refer strictly to STIs, others are broader. Health professionals who deliver sexual health services argue that a broader definition would be cost-effective in the long term. This approach would raise awareness of the sexual health clinics thereby enhancing access, quality of care and cost-effectiveness.

Second, the decision of the Health Funding Authority to separate the funding streams into primary, secondary and tertiary care is designed to reduce the cost of specialist and specialised sexual health services because they will treat only those patients who have been referred by a medical practitioner. GPs and otherproviders, such as Family Planning, are expected to cover self-referrals or what the Health Funding Authority have termed primary health service needs.

As discussed above, this method is not supported in the literature, where it is argued that specialised and dedicated sexual health clinics must have multiple entry points to be cost effective and efficient.3,4 In addition, a recent New Zealand study on chlamydia found that specialised sexual health clinics were more likely to: correctly screen on the basis of age; apply proper testing procedures; identify the tests used by their laboratory for accurate test interpretation; and conduct thorough contact tracing(9).

While a Hospital and Health Service may have high corporate overheads, the removal of specialised sexual health clinics from Hospital and Health Services or a narrow concentration on secondary care will lead to greater fragmentation. With this fragmentation will come greater costs for rent, management, and a possible increase in the number of STIs. These increased costs will exceed any short-term financial savings associated with transferring sexual health services to other organisations.

Third, the Health Funding Authority limits funding through a national funding formula that has insufficient regard for the specialised and more costly treatments provided in a main specialist centre. This includes an underestimation by the Health Funding Authority of the cost of visits as well as the number of patient visits and the number of follow-ups required. This has recently contributed to the decision made by Capital Coast Health to exit the sexual health service. Unless a critical mass of patients and therefore disease is controlled, public health goals will not be achieved.

The Health Funding Authority’s decision to limit funding to a specified number of patient visits does not allow for a potential increase in STIs. For instance the sexual health staff at Capital Coast Health are aware of an increase in gonorrhoea, which may be above previously reported figures. Chlamydia cases may also have increased over previous years. These suggest an increase in patient numbers without a corresponding increase in funding to meet public health obligations.

Conclusion

Given the private nature and social stigmas associated with sexual health it is vital to create a service structure that facilitates simple and unrestricted access to treatment and diagnosis. On the basis of their experience and research, sexual health professionals recognise that the most effective structure for the delivery of sexual health care is centred on specialised and comprehensive specialist services located within major Hospital and Health Services.

Smaller satellite sexual health clinics should be located in provincial areas. These should be co-ordinated by a centralised public health ‘watch dog’ agency including sexual health specialists. This agency would seek to ensure equitable service provision and disease control throughout New Zealand. This would preserve an integrated service and ensure efficient and effective treatment for patients.

The public health benefits for retaining sexual health services within Hospital and Health Services are important. There is no evidence or experience that an alternative provider will be able to offer the required level of integration and comprehensiveness to cope with the specialised and specialist needs of the sexual health service. Funding and policy decisions should seek to improve collaboration between existing services spanning primary, secondary and tertiary care.

References

Bennett, S., McNicholas, A., & Garrett, N., (December 1998). Screening, Diagnostic and Treatment Practices for Chlamydia Infections in New Zealand. Institute of Environmental Sciences & Research (ESR): Porirua.

Institute of Medicine, (1997). The Hidden Epidemic: Confronting sexually transmitted diseases. Eng, T.R., & Butler, W.T., (Eds), Institute of Medicine, Division of Health Promotion and Disease Prevention: United States.

Levy, M., (1998). Impact of closure of a sexually transmitted disease clinic on public health surveillance of sexually transmitted disease - Washington DC, 1995. MMWR Weekly, 47(49), 1067-9.

Lyttle, P.H., & Say, P.J., (unpublished 1992). The Development of STD Services in New Zealand from VD to Sexual Health: Appendix 2.

Ministry of Health (1998). Sexually Transmitted Diseases: Prevention and Control, the public health issues 1996-1997. Ministry of Health: Wellington

Morsubu, L., & Veroni, M., (1996). The Annual Report of Sexually Transmissible Diseases Western Australia, 1995.

Public Health Group (January 1996). Prevention of Sexually Transmitted Disease: A discussion document. Ministry of Health: Wellington, P53.

Wellington District (1990). Sexual Health Service Interim Report / Plan, p16.

Footnotes

1. Wellington District (1990), p16.
2. Lyttle & Say, 1992.
3. Institute of Medicine, 1997.
4. Levy, 1998.
5. Morsubu & Veroni (1996).
6. Public Health Group (January 1996).
7. Dickson et al (1996), cited in Ministry of Health (1998), p26.
8. Ministry of Health (1998).
9. ESR (December 1998).