Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical Services Sexual Health April 2003 Sexual Health 1 Sexual health This general practitioner with special interest (GPwSI) framework is one of a number which the Department of Health has commissioned the Royal College of General Practitioners (RCGP) to produce. The frameworks have been written following extensive consultation with general practitioners, secondary care specialists, Primary Care Trust managers, patients, the Department of Health and the PwSI team in the NHS Modernisation Agency. The frameworks are intended to be advisory for the development of local services, providing good practice and experience, offering recommendations to assist PCOs in determining how to implement a local GPwSI service to meet their needs. This guidance should be read in conjunction with the Department of Health and Royal College of General Practitioners’ Implementing a scheme for General Practitioners with Special Interests (April 2002, www.doh.gov.uk/pricare/gp- specialinterests), and the NHS Modernisation Agency’s Practitioners with Special Interests: A Step by Step Guide To Setting Up a General Practitioner with a Special Interest (GPwSI) Service (April 2003, www.gpwsi.org). Rationale for GPwSI service in sexual health The risk of unwanted pregnancy and the risk of sexually transmitted infections are often associated with each other. Evidence showing associations between mental ill-health, drug and alcohol problems and sexual ill-health and high-risk sexual behaviour supports the need for a GPwSI to take a broader approach to sexual health. a. The core activities of a GPwSI service in sexual health It is recommended that the National Strategy for Sexual Health and HIV (www.doh.gov.uk/nshs/bettersexualhealth.pdf) and the subsequent Tool Kit for Primary Care Trusts (www.doh.gov.uk/sexualhealthandhiv/pdfs/commissioning_toolkit.pdf) should underpin the development of a GPwSI service. The activities of a GPwSI service will depend on a number of factors, including the location of the service and its overall aims. In principle ,the main activities of the service will be based around education and improving standards of sexual health medicine within the primary care organisation as well as offering sexual health services. As best practice, it is recommended that GPwSI services include elements of the following: Clinical Service Offering Level 1 services with some additional Level 2 services (see table 1). These services can be offered either as part of an integrated general practice service with care being provided alongside other general medical services or as a stand-alone service located within a dedicated sexual health clinic within the NHS Sexual Health 2 or other provider and either targeted to a particular population or risk group (e.g. young people, drug users, hard-to-reach groups) or provided to a general population. At the time of writing much work has been done to ensure that GP practices are able to provide level 1 services. Therefore an initial role of a GPwSI service may be to support this further. Further activities of the GPwSI service depend on the needs of the Primary Care Organisation (PCO) and can include provision of: - • Enhanced Family Planning services. • Menopause care. • Infertility care. • Service to raise the awareness and respond to the needs of women who have undergone female genital mutilation. • Vasectomy services. • Psychosexual counselling. Education and Liaison This usually involves dissemination of good practice across the PCO training and education, liaison with local specialist providers, and local laboratories. Service Development/Leadership • Contribute to the strategic direction of local sexual health services in particular lead implementation of the National Strategy; participate in the monitoring of outcomes and support development of integrated services. • Provide sexual health clinical leadership for primary care in order to champion change. Sexual Health 3 The National Strategy for sexual health and HIV.ational for sexual health and Level 1 Services Sexual history and risk assessment. Sexual Transmitted Infections testing for women. HIV testing and counselling. Pregnancy testing and referral. Contraceptive information ad services. Assessment and referral of men with STI symptoms. Cervical cytology screening and referral. Hepatitis B immunisation. Level 2 Services Intrauterine device insertion. Testing and treating sexually transmitted infections. Vasectomy. Contraceptive implant insertion. Partner notification. Invasive sexually transmitted testing for men (until non-invasive tests are available). The RCGP is of the view that a Level 1 service should also include the ability to provide a confidential service and a service accessible to young people. New draft GMS contract The new draft GMS contract includes a number of quality markers relevant to sexual health medicine. The GPwSI would have an important role in helping practices reach the quality targets as well as supporting PCOs in developing and monitoring Enhanced services. b. The core competencies recommended for the GPwSI service These will depend on the core activities of the service provided though a GPwSI should be able to demonstrate elements of those listed below. Generalist The competencies to deliver a GPwSI service should be seen as a development of generalist skills including good communication skills, competence in teaching and training health care professionals and a commitment to cascading knowledge and skills. and Special interest area A GPwSI would be expected to be competent at providing all Level 1 services to a high level of expertise. Sexual Health 4 Competencies Clinical Education and support Leadership Knowledge of: Local and national epidemiology, presentation, natural history, complications, investigation, treatment (including antibiotic resistance) of the common Sexual Transmitted Infections and vaginal infections. Harm reduction and harm minimisation in relation to illicit drug use, especially injecting drug use. Use and contraindications of the full range of contraceptive techniques. Methods for TOP, their relative advantages and disadvantages indication and contraindications. Understanding of the different test for STIs including storage and transport of specimens. Understanding of practice based methods of record keeping and how these may support audit. Indicators of sexual health risk. Local STI and Family Planning services and supports available. Good knowledge of local guidance in relation to treatment of common STIs. Local management of sexual contacts and partner notification. Epidemiology and prevalence of STIs and Teenage pregnancy, and other relevant local sexual health issues, e.g. female genital mutilation, sickle cell disease. Legal framework of STIs in primary care including that relevant to young people and confidentiality. Knowledge of local educational providers. National, local and Professional strategies and guidelines and how these may relate to service configuration within the PCO. Good understanding of roles, responsibility and structure of PCOs and how to influence them to bring about improvement in delivery of sexual health services. Understanding of primary care structures and how these may affect delivery of services within the PCO. Understanding of service redesign and care pathways. Skills Able to carry out a full sexual and contraceptive history including risk assessment. Able to keep up to date with national and local priorities, treatment changes and services. Able to work across clinical networks with specialist and other services. Sexual Health 5 Competencies Clinical Education and support Leadership Able to carry out sexual health risk assessment and offer harm reduction advice. Able to perform male and female genital examination and recognise abnormal findings. Able to demonstrate condom use. Able to carry out cervical cytology. Able to report STIs according to minimum date set requirements. Able to liaise with educational providers delivering training etc to primary care practitioners, e.g. deanery structures, PCO protected learning events. Attitudes Able to engage with patient group in a manner that facilitates good history taking and treatment of sexual health problems. Able to work in a multidisciplinary team and use other members of the team. Other competencies will be determined by the activities provided, for example • Able to perform colposcopy examination and treatment. • Able to perform vasectomy. • Able to provide psychosexual counselling services. • Able to test and treat sexually transmitted infections in men and women. • Able to fit and remove Intra Uterine Contraceptive Devices, including Intra Uterine Systems. • Able to fit and remove contraceptive implants. c. Evidence of training and experience for required competencies Generalist skills PCOs will need to ensure that the GP is a competent and experienced generalist, as well as having the specific competencies and experience for the special interest area. This can be assessed in a number of ways but is readily demonstrated by GPs Sexual Health 6 who have passed the Examination of the RCGP and who are current members of the College. and Skilled at training health care professionals and Special interest Evidence of working under direct supervision with a specialist clinician in relevant clinical areas. The number of sessions should be sufficient to ensure that the GPwSI is able to meet the competencies of the service requirements, the skill being assessed and the level of expertise required. For those clinicians with little or no experience in relevant clinical areas this is likely to be in the region of 40 – 50 clinical sessions. or Personal development portfolio showing evidence of relevant clinical skills and knowledge. and Evidence of attendance at relevant courses (for example, family planning www.ffprhc.org.uk) or self directed learning to meet learning gaps identified through the professional development plan and annual appraisal. d. Evidence of acquisition The RCGP recommends that GPwSI in all areas maintain a personal development portfolio to identify educational requirements matched against the competencies required for the service, and evidence of how the learning needs have been met and maintained. This portfolio can serve as a training record, counter-signed as appropriate by an Educational mentor or supervisor/s to confirm the satisfactory fulfilment of the required training experience and the acquisition of the competencies enumerated in this document and others thought necessary by the employing authority. This portfolio should form part of the GPwSI annual appraisal. and Evidence of delivering a sexual health service of quality within his/her general practice. Sexual Health 7 Examples of different evidence of competencies for the service. • Demonstration of skills under direct observation by a senior clinician. • Demonstration of knowledge by personal study supported by appraisal. • Evidence of gained knowledge via attendance at accredited courses or conferences. • Demonstration of ability to work in teams by evidence of taking part in multidisciplinary teamwork to plan and deliver service provision and individual patient care. • Delivering multi- and uniprofessional training. • Base line experience working as a clinical assistant. e. Evidence of maintenance of competencies The GPwSI would be expected to maintain his or her competencies through continued professional development and education. It is recommended that he or she undertakes a minimum of 15 hours CPD and undergoes annual appraisal in the special interest and generalist areas. It would be good practice for CPD to include multiprofessional and disciplinary learning. Close links with specialist colleagues and others working in the field is important for maintenance of competencies. In order to maintain skills and expertise, it is recommended that the GPwSI spend at least one session per week (ideally more) working in the special interest area and at least one session per week (ideally more) in working as a generalist. It is important that the GPwSI maintains some direct patient contact in the special interest area. Membership of a relevant national primary care organisation or network would add to this portfolio. f. Accreditation process This involves determining the core competencies for the special interest area, evidence required to demonstrate these competencies and criteria for maintenance as defined in this framework. These criteria have been set nationally following stakeholder consultation. Before appointing a GPwSI the PCO should ensure that the doctor has submitted evidence of his or her required competence to the expected standard defined by these criteria for accreditation. The mechanism for this process can be determined locally although it is recommended that it should be through an assessment of evidence of competence contained in the practitioner’s ongoing personal development portfolio by local Sexual Health 8 (e.g. Clinical Governance Lead, Medical Director, local specialist) and/or national (representative from Professional body or Special Interest Primary Care Organisation) assessors, where at least one assessor has in-depth specialist knowledge of the clinical area. The PCO would be expected to provide a working environment as part of the GPwSI post that enables the doctor to practise the special interest area in a competent manner. g. The types of patients suitable for the service including age range, symptoms, severity, minimum and maximum caseload/frequency and reason for referral The details of the service depend entirely on the location and type of service offered as listed above. Services may, for example, be located within a primary, secondary or non-statutory service, be direct access or through appointment, targeted or universal, gender or sexual orientation specific. The service configuration will depend on the needs of the PCO and other local factors. In all GPwSI services the caseload should be sufficient such that the GPwSI is able to exercise their generic skills and deal with the physical, psychological and social aspects of disease. The GPwSI should be able to demonstrate that their skills are actively used and audited, including evidence of development and adherence to national and local guidance. h. Local guidelines on the use of the service These will be determined at local level and may include information for referring clinicians about • Referral pathways. • Communication pathways. • Inclusion and exclusion criteria for patients referred or treated by the service. i. The facilities recommended for delivery of GPwSI in sexual health service Although these will be determined by the service being provided, the following should ideally be present irrespective of the location or configuration of the service: • Access to mentoring/educational supervisor. • Direct access to specialist support. • Access to educational and relevant material, including provision of courses, conferences and protected time for CPD. • Access to a network of professionals working within the special interest area. Sexual Health 9 • Written confidentiality agreement for the service and other members of the team. • Appropriate sensitive and specific diagnosis tests for Chlamydia and other STIs. • Access to health advisor. • Clear sign-posting in the waiting room and practice leaflets to sexual health service available in the practice and elsewhere. • Access to medical and surgical Termination of Pregnancy providers. • IT facilities with Internet access. j. Clinical governance, accountability and monitoring arrangements, including links with others working in the same clinical area in primary care, at PCT level and in acute trusts The GPwSI will be accountable to the PCT Board with clinical responsibility resting with the GPwSI. The Clinical Governance arrangements will follow those normally used for the PCT and should include systems or mechanisms for defining clinical audit and communication standards, significant event monitoring and complaint handing. The GPwSI service should have good mechanisms for joint working and communication, including regular meetings with other service providers (e.g. family planning specialists, GUM specialists, nurse specialists). k. Induction and support arrangements for the GPwSI The induction process may include the following elements: • Risk management. • Networking with other professionals. • Involvement in national clinical networks. • Clinical Governance arrangements. • Audit and reporting mechanisms. The GPwSI should have the appropriate funds and time for continuing professional development, including attendance at multiprofessional team meetings, audit events, relevant courses and conferences. The GPwSI should have access to an educational mentor, who may be a clinician with special interest in Sexual Health or other relevant professional. [...]...Sexual Health l Monitoring and clinical audit arrangements This should be determined locally; however it is recommended that the monitoring process should include an assessment of the service ability to meet unmet or unrecognised needs and hence the service should demonstrate an increase in opportunistic sexual health care, STI testing and an increase in referral for sexual health services to GPwSI colleagues . Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical Services Sexual Health . in conjunction with the Department of Health and Royal College of General Practitioners Implementing a scheme for General Practitioners with Special Interests