[PUBLIC ADMINISTRATION OF PERSONNEL POLICY IN REFORMING OF UKRAINIAN HEALTH CARE SYSTEM USING THE EXAMPLE OF DERMATOVENEREOLOGICAL SERVICE]

The health care system, its modernization and optimization are among the most important functions of the modern Ukrainian state. The main goal of the reforms in the field of healthcare is to improve the health of the population, equal and fair access for all to health services of adequate quality. Important place in the health sector reform belongs to optimizing the structure and function of dermatovenereological service. The aim of this work is to address the issue of human resources management of dermatovenereological services during health sector reform in Ukraine, taking into account the real possibility of disengagement dermatovenereological providing care between providers of primary medical care level (general practitioners) and providers of secondary (specialized) and tertiary (high-specialized) medical care (dermatovenerologists and pediatrician dermatovenerologists), and coordinating interaction between these levels. During research has been found, that the major problems of human resources of dermatovenereological service are insufficient staffing and provision of health-care providers;,growth in the number of health workers of retirement age; sectoral and regional disparity of staffing; the problem of improving the skills of medical personnel; regulatory support personnel policy areas and create incentives for staff motivation; problems of rational use of human resources for health care; problems of personnel training for dermatovenereological service. Currently reforming health sector should primarily serve the needs of the population in a fairly effective medical care at all levels, to ensure that there must be sufficient qualitatively trained and motivated health workers. To achieve this goal directed overall work of the Ministry of Health of Uktaine, the National Academy of Medical Sciences of Ukraine, medical universities, regional health authorities, professional medical associations. Therefore Ukrainian dermatovenereological care, in particular fixed, needs a deep and objective medical and social audit. A necessary condition for the harmonious development of dermatovenereological service is adequate staffing to ensure it to reflect changes in the structure of the provision of the assistance at various levels, as well as their effective coordination throughout the natient's medical route.

[The characteristics of medical manpower of dermatologic venereal service at the territorial level]

The article presents the medical social characteristics of medical manpower af dermatologic venereal services of Ryazan, Tula and Lipetsk oblasts from the position of quality of specialized medical care of population.

The place of routine HIV testing

In 2009, around 86,500 people in the UK had HIV infection, of whom around a quarter were unaware of their condition. Of adults diagnosed in that year, around half were already at a late stage of disease (with a CD4 count below 350 cells/μL or presenting with an AIDS-defining event). Such late diagnosis represents a missed opportunity for treatment and prevention, and is associated with significant morbidity and mortality, reduced response to antiretroviral drugs and increased healthcare costs. In genitourinary medicine (GUM) clinics and during antenatal care, there is a high uptake rate of routine testing (i.e. HIV tests are offered as part of standard care and the individual has the option to decline). Increasing such testing across other healthcare settings could reduce late diagnosis. Here we examine issues around routine HIV testing.

Sexual health in adolescents

“Saved sex” and parental involvement are key to improving outcomes

Success of a nurse led community based genitourinary medicine clinic for young people in Liverpool: review of the first year

OBJECTIVES

To assess the outcome and workload of a community based, nurse led comprehensive sexual health and contraceptive service for clients aged less than 25.

METHODS

Review of appointment diaries and clinic records of clients who attended the Brook genitourinary medicine (GUM) clinic. The workload, case mix, and achievement of national targets in the first year of the service were compared with those for the same age group of clients attending the nearby hospital based GUM clinic. A limited client satisfaction questionnaire was carried out 8 months after the clinic opened.

RESULTS

1061/1700 (62.4%) clients (185, 17.4% male) attended booked appointments. Chlamydia trachomatis was detected in 16.1% of women and 20.5% of men at Brook (p<0.05), where 22.6% of women and 50% of men had at least one sexually transmitted infection (p<0.001). HIV testing was offered to 98.5% of clients. 60.7% of all identified contacts attended a clinic for testing and/or treatment. Client responses to a questionnaire about the service were very favourable. Only 2.3% of Brook GUM clients needed referral to a physician.

CONCLUSIONS

Nurse led community based GUM services, such as the one provided at the Merseyside Brook Centre, appeal to young people and our success should encourage others to consider similar ventures.

One stop shop versus collaborative integration: what is the best way of delivering sexual health services?

OBJECTIVES

To examine various models of integrated and/or one stop shop (OSS) sexual health services (including general practice, mainstream specialist services, and designated young people's services) and explore their relative strengths and weaknesses.

METHODS

Literature review and interviews with key informants involved in developing the National Strategy for Sexual Health and HIV (n = 11).

RESULTS

The paper focuses on five broad perspectives (logistics, public health, users, staff, and cost). Contraceptive and genitourinary medicine issues are closely related. However, there is no agreement about what is meant by having "integrated" services, about which services should be integrated, or where integration should happen. There are concerns that OSSs will result in over-centralisation, to the disadvantage of stand alone and satellite services. OSS models are potentially more user focused, but the stigma that surrounds sexual health services may create an access barrier. From staff perspectives, the advantages are greater career opportunities and increased responsibility, while the disadvantages are concern that OSSs will result in loss of expertise and professional status. Cost effectiveness data are contradictory.

CONCLUSION

Although there is a policy commitment to look at how integrated services can be better developed, more evidence is required on the impact and appropriateness of this approach.

Public involvement in modernising genitourinary medicine clinics: using general public and patient opinion to influence models of service delivery

OBJECTIVES

To determine which of the options available to modernise genitourinary medicine (GUM) clinics in the UK are most acceptable to patients and potential patients; to assess whether the views of a general population sample differ from those of clinic attenders. .

METHODS

A questionnaire was used to explore the acceptability of different ways of delivering sexual healthcare including the potential trade-off between convenience/range of services with cost/staffing constraints. Potential differences in responses by age, sex, ethnicity and current attendance at a GUM clinic were evaluated using multivariate analysis.

RESULTS

542 respondents in the community and 202 clinic attenders provided responses. Delivery of sexual healthcare by specialist nurses and general practitioners was acceptable to 81% and 72% of interviewees, respectively, assuming common protocols were adhered to. The proportion of individuals who would accept a consultation with a nurse increased to 91% if the waiting time for an appointment could be reduced as a result. Men were less likely to accept a consultation with a nurse (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.35 to 0.79), and Asian (OR 0.38, 95% CI 0.23 to 0.64) and other black (OR 0.41, 95% CI 0.2 to 0.87) ethnic groups were less likely to accept a consultation with a general practitioner. 44% of patients preferred walk-in clinics even if waiting times for an appointment were reduced to 48 h.

CONCLUSION

Delivery of sexual healthcare by nurses and general practitioners was generally found to be acceptable, although this varies by patient sex and ethnicity. Some differences exist between the preferences of a general population sample compared with clinic attenders, but overall there is a high level of concordance. Walk-in clinics remain a popular choice even when appointment waiting times are short.

"We don't really have cause to discuss these things, they don't affect us": a collaborative model for developing culturally appropriate sexual health services with the Bangladeshi community of Tower Hamlets

OBJECTIVE

To identify barriers to accessing sexual health care among the Bangladeshi community of east London and to develop a model of community participation in service development.

METHODS

Qualitative study using one to one interviews with sexual health service users plus focus groups in community settings.

RESULTS

58 people participated in the study, 12 in individual interviews and the remainder in six focus groups. All were of Bangladeshi origin. Four main themes were reported as impacting on access to services; confidentiality concerns, relevance of services to the community, problems with discussing sexual issues, and problems with previous experiences of health promotion. Community values regarding sex outside of marriage were an important underlying factor in participants' responses. Existing sexual health services were seen as culturally insensitive by patients and community groups.

CONCLUSIONS

Community based health initiatives among hard to reach ethnic minority groups should use existing networks of statutory and non-statutory groups to benefit from local expertise and relationships. Steering groups composed of members of the local communities served by the clinic can usefully inform service development.

Can mainstream services learn from male only sexual health pilot projects?

Over the past decade a number of community based sexual health projects aimed solely at young men have proved to be very successful at attracting young men into genitourinary medicine services. These projects are often short term funded and under evaluated so it isn't clear exactly how successful they are and why this might be so. These projects should be carefully evaluated and examined to elicit factors, either unique or common in nature, which could be utilised by mainstream sexual health services wishing to develop work with young men. There are many barriers to this happening in mainstream services, some being resource and time problems and others to do with values of staff and lack of quality training. The article looks at practical ways that working with men and the skills and confidence of staff can be improved in mainstream settings while recognising that much of what needs to be done to support the needs of young men must take place in the planning and commissioning stage of services.

The 374 clinic: an outreach sexual health clinic for young men

OBJECTIVES

To describe the establishment of a community based walk-in outreach genitourinary medicine clinic, the "374 clinic," in south London to target young men under 25 in an area with high rates of sexually transmitted infections (STIs).

METHODS

The outreach clinic was set up within a Brook advisory centre, which already had gained the trust of local young people. Epidemiological, clinical, and laboratory data were obtained retrospectively for the first 24 weeks of the service.

RESULTS

134 attendances were recorded, including 94 new and 10 rebook events. The age range of the young men seen was 12-27 years (mean 18.2 years), the patients were mainly from black and ethnic minority groups, and all but one were heterosexual. Most men had heard about the clinic by "word of mouth," recommendation by Brook staff or through clinic promotional material. Condoms were used more frequently with non-regular sexual partners than with regular partners. The uptake of screening for gonococcal and chlamydial infections, mostly by urine based molecular techniques, was 98%. The uptake for HIV testing in men aged 16 or more was 72%. An overall STI prevalence rate of 26% was detected in the clinic population, which consisted almost equally of asymptomatic and symptomatic patients. The most prevalent STI was chlamydial infection (12%).

CONCLUSIONS

The young men who attended the outreach clinic were happy to undergo both non-invasive urine based testing for gonorrhoea and chlamydia as well as phlebotomy to test for HIV and syphilis. The 374 clinic approach may prove to be a useful model for further outreach services to combat poor sexual health of young men in inner city areas.

The impact of decentralisation on sexual and reproductive health services in Ghana

This paper analyses the impact of decentralisation on the political organisation, management and provision of sexual and reproductive health services in Ghana. It draws on qualitative research and interviews with key informants from the Ministry of Health, donors, NGOs, regional and district health management teams, local government and community leaders. Within a national reproductive health policy framework, previously disparate family planning, maternal and child health, STI and HIV/AIDS programmes have become more integrated, and donors have pooled or co-ordinated their funding. Some decision-making about resource allocation is meant to happen at district and regional level but in practice, this remains centrally controlled, which may be a necessary safeguard for sexual and reproductive health services. Earmarked donor funds still ensure a regular supply of contraceptives and STI drugs. However, paying for these is problematic at local level. Sexual and reproductive health staff make up a large proportion of primary health care staff, but especially in rural areas they experience poor working conditions, and there is high turnover and vacancies. District and sub-district level links are working well in this new system, but clarity is still needed on how different national sexual and reproductive health bodies relate to each other and to regional and district health authorities. The development of formal mechanisms for priority setting and advocacy at local levels could help to secure benefits for sexual and reproductive health care.

Sexual health clinics for women led by specialist nurses or senior house officers in a central London GUM service: a randomised controlled trial

OBJECTIVES

To assess the care process and clinical outcomes for two different models of GUM clinic for women: one led by specialist nurses and the other by senior house officers (SHOs).

METHOD

An open randomised controlled trial was carried out in a central London genitourinary medicine (GUM) women's clinic. Of 1172 women telephoning for an appointment, 880 were randomised to provide 169 eligible patients in the specialist nurse arm and 178 in the SHO arm. Of the eligible patients a total of 224 attended their appointment. The clinical records of the randomised women were audited for adequacy of care according to local guidelines. 30 key variables were objectively assessed and recorded on a standard audit form. An overall unitary index score (%) was calculated for each patient. The main variables associated with the outcome of specialist nurse and SHO decision making (diagnostic test request, preliminary diagnosis, and treatment provided) were then analysed independently.

RESULTS

The median documentation audit scores for specialist nurses (n=103) and SHOs (n=121) were 92% and 85% respectively (p<0.0001). The specialist nurses' documentation was significantly (p<0.05) more complete than the SHOs' for five variables: details of menstrual cycle, physical examination, medication instructions given to patients, health promotion discussion, and provision of condoms. Specialist nurses performed equally to the SHOs with regard to requesting the correct diagnostic tests, providing the correct preliminary diagnosis, and providing the correct treatment.

CONCLUSIONS

A model of care using trained GUM nurses working within agreed protocols can provide comprehensive patient care for female patients that is equal to care provided by SHOs. Our results raise important issues regarding advanced GUM nursing education and training, protocol development, and accountability.

A postal survey to identify and describe nurse led clinics in genitourinary medicine services across England

BACKGROUND

Nurses in genitourinary medicine (GUM) services are progressively extending their roles to conduct "comprehensive care" nurse led clinics. In such roles the nurse coordinates the first line, comprehensive care of patients presenting with sexual health conditions and issues.

OBJECTIVES

To identify and describe comprehensive care nurse led clinics in GUM services across England.

METHODS

A postal questionnaire consisting of 17 closed response questions was sent to 209 GUM services across England. A second questionnaire was sent to non-responders to increase the response rate. Data were single entered and analysed using SPSS.

RESULTS

Of the 190 GUM clinic respondents (91% response rate), 44 (23%) reported providing some form of comprehensive care nurse led clinic, 90% of which were initiated since 1995. Key results show staff development featured as the main reason for initiating such services and there was general consistency in the aspects of care undertaken by these nurses. There was evidence of guideline development specific to nurse led care and some patient group direction use for supplying medication. The level of support from medical staff while nurse led clinics were being conducted varied between services. Few services have conducted any audit or research to monitor/evaluate nurse led care. There was little consistency in the clinical experience and educational prerequisites to undertake comprehensive care nurse led clinics. Continuing professional development opportunities also varied between services.

CONCLUSIONS

The steady growth of comprehensive care nurse led clinics indicates that the skills of GUM nurses are being recognised. Nurses working in advanced practice roles now require courses and study days reflecting these changes in practice. Locally agreed practice guidelines can define nursing practice boundaries and ensure accountability, as will the development of patient group directions to supply medication. Monitoring and evaluation of nurse led clinics also require attention.

The national strategy for sexual health and HIV: implications for genitourinary medicine

The first ever national strategy for sexual health and HIV in England was published in July 2001 and proposes a comprehensive and holistic model for dealing with an increasing public health problem. The strategy covers the issues of prevention, service provision, commissioning of services, and the necessary requirements to support change. This paper concentrates on service issues and developments in relation to genitourinary medicine/HIV services, and outlines a model for providing these which attempts to do so around patients' needs, delivered through comprehensive and interlinked local networks of services.

Outreach health adviser in a community clinic screening programme improves management of genital chlamydia infection

OBJECTIVE

To assess the effectiveness of an outreach health adviser on treatment, partner notification and outcome for clients diagnosed with genital chlamydia (CT) infection at a community young people's clinic.

METHODS

From August 1999 to March 2000, a genitourinary medicine (GUM) based health adviser helped to develop testing and undertook outreach management of clients aged under 26 years diagnosed with CT infection. In addition to facilitating referral to GUM, she gave antibiotic treatment based on a GUM derived patient group direction to those not wishing to travel to the GUM clinic. She also advised them on contact tracing and the need for a compliance check (CC).

RESULTS

Chlamydia positive tests with ligase chain reaction (LCR), on first void urine, were obtained for 62 (12.9%) of 481 female clients, one (5%) of 20 male clients, and nine (53%) of 17 male contacts of female positive cases. All 72 testing positive received their result and were treated. Two urine samples positive for CT showed positive LCR tests for gonorrhoea. Proportions of named contacts seen (67%) and reattendances for compliance checks (60%) were similar to those for women seen in GUM services.

CONCLUSIONS

Health adviser input with the ability to treat can be effective in reducing the growth of identified but untreated genital chlamydia infection consequent upon community based screening. Such a strategy appears comparable with, and can add to, GUM based treatment of infection. It helps to address the need for alternative management strategies in the light of the national sexual health strategy.

Governmentality, the iconography of sexual disease and 'duties' of the STI clinic

Sexually transmitted infections (STIs) have come to occupy a different social space over the last hundred years, where the iconography of disease has moved from purity to consumption of desire, and where the regulation of disease has moved from moral proscription to governmentality. These processes are represented through health promotion campaigns where the medico-moral discourses appropriated both the iconography of pathology and the construction of the family as the site of moral surveillance and governmentality. This paper will consider how the 'duties' of STD clinics have been defined and mark a paradigmatic statement of the panoptic role of medicine in the mapping of the social and psychological spaces between individuals. Sexual health medicine, together with health promotion ideologies, has claimed privileged status through the deployment of expert, clinical knowledge and rationalities, to penetrate the sexual praxis of populations. In so doing, it also underscored the individual's roles and responsibilities in the ideological work of the changing constructions of sexual citizenship, from moral purity to ars erotica, as well as the increasing intervention of the state in reproduction and control of sexualities.

Cervical cytology smears in sexually transmitted infection clinics in the United Kingdom

OBJECTIVES

To determine the current practice of smear taking in sexually transmitted infection (STI) clinics within the United Kingdom; what proportion of smears are taken within the national guidelines; whether clinics are screening women not covered by the national screening programme. To compare the abnormality rates of routine and opportunistic (that is, in addition to the screening recommendations) smears; the abnormality rates of smears taken within STI clinics with those taken within the community setting.

METHODS

A questionnaire was circulated to all clinics in May 1998. Details of screening practice were requested. The clinics then prospectively collected details of patient's age, GP registration, date and result of previous smear, and current result of all smears taken between 11 May 1998 and 25 May 1998.

RESULTS

There were 1828 smears taken in the 2 week period; 504 (27.6%) were opportunistic. Opportunistic smears had marginal significantly increased rates of low grade abnormalities but lower (but not statistically significant) high grade abnormalities than in routine smears. 231 (12.6%) of the women were not registered with a GP so would not be included in the national programme. The national rates of abnormalities were significantly higher in the STI clinics compared with the community setting.

CONCLUSION

The majority of smears taken within STI clinics fall within the national guidelines, and 12.6% of the women would probably not otherwise have been screened. The rates of abnormality were significantly higher in the STI clinics but smears taken opportunisticly were less likely to have high grade abnormalities. There is no evidence from this study to support the practice of additional smears in the presence of an effective national cytology screening programme.

Epiluminescence microscopy versus clinical evaluation of pigmented skin lesions: effects of Operator's training on reproducibility and accuracy. Dermatology and Venereology Society of the Canton of Ticino

BACKGROUND

An acceptable level of reliability is a prerequisite for the introduction of epiluminescence microscopy (ELM) into the diagnosis of pigmented skin lesions.

OBJECTIVE

To assess the effects of a training program on the reproducibility and accuracy of ELM as compared to clinical evaluation.

METHODS

Before and after the program, 48 clinical images and their ELM counterparts were independently evaluated by seven participants. Reproducibility was measured by the kappa index, accuracy by the rate of exact diagnoses (RED) assuming histology as a reference.

RESULTS

We observed (i) no effect of training on clinical reproducibility, (II) an improved reproducibility of ELM diagnoses of non-melanocytic lesions (NML) and melanomas but not of melanocytic nevi (MN), (iii) a greater increase in the clinical RED of NML and melanomas compared with MN and (iv) a similar though more pronounced increase in the RED on ELM.

CONCLUSIONS

The effects of training were greater for ELM as compared to clinical diagnosis, and for NML and melanomas as compared to MN.

Follow up by telephone. Genitourinary medicine clinic gives results by telephone

Images

Genitourinary medicine services; consumers' views

Three hundred patients attending a department of genitourinary medicine were asked their opinion of various aspects of the current services and those which should be provided in a new department. A majority of patients wanted the clinic to be open in the evening and to be sited away from the main out-patients department. Three quarters of the patients wanted to maintain an open access system although more than half would have liked appointments to be available. A small majority wanted to be addressed by name rather than number. Nineteen per cent of men and 50% of women wished to be examined by a doctor of the same sex but only 16% of men expected to be examined by a male nurse. Most patients did not want the result of the consultation to be sent to their general practitioner (GP) without their consent but 71% of women agreed to their GP being informed of the result of their cervical cytology test.