Career: Let's talk about sex

THE UK has often been cited as having the worst sexual health in Europe. And while recent statistics have shown improvements are being made, there remains a need for GPs with a special interest (GPwSI) in this field.

Official figures paint a mixed picture. A report by the Office for National Statistics in 2013 showed the estimated number of pregnancies amongst under-18s is at its lowest level since records began in 1969. In contrast, the number of pregnancies in women of all ages is at its second highest level.

Meanwhile, last February the Health Protection Agency raised concerns that fewer gay/bisexual men in the UK are using condoms, fuelling a rise in HIV infections in those groups.

Entry and training

Training can be acquired in several ways for GPwSIs in sexual and reproductive health and would include both practical and theoretical elements. Common elements include working under the supervision of a specialist or consultant in sexual health/genito-urinary medicine; self-directed learning; a recognised university course or accredited training. An attachment in a community contraceptive clinic/GUM clinic is also beneficial to enable the practical development of skills in STI management, common contraceptive problems, intra-uterine devices/intra-uterine systems (IUD/IUS) and contraceptive implant fittings under appropriate supervision to acquire sufficient expertise and help with network development.

The RCGP sets out a number of competences for GPwSIs in sexual health although practitioners are not expected to have all those listed. These include:

• Screening and health promotion
• Taking a sexual history
• Genital examination
• Advice about safer sex
• Contraception
• HIV
• Sexual assault and female genital mutilation
• Managing children and young people within the sexual health service
• Partner notification
• Referral pathways
• Epidemiology.

As a minimum, it is recommended that the GPwSI takes the Sexually Transmitted Infection Foundation (STIF) course (or equivalent) and completes the associated logbook of competences and/or holds the DFSRH – the Diploma of the Faculty of Sexual and Reproductive Healthcare, with the appropriate letters of competency in sub-dermal implants and intra-uterine techniques.

Some practitioners may wish to obtain the Diploma in GU Med and/or HIV as their learning objectives or membership of the Faculty of Sexual and Reproductive Healthcare. Clinicians wishing to offer IUD/IUS and sub-dermal contraceptive implant services should have completed training and have been deemed competent to provide such services.

It is also recommended to join an appropriate faculty/professional group/primary care sexual health organisation – such as the FSRH – to help further develop knowledge and skills.

The job

The approach to sexual health varies across the UK. In England, responsibility for commissioning most sexual health services now falls to local authorities. The Department of Health published its Framework for Sexual Health Improvement in England last year which highlighted the need to reduce unintended pregnancies and sexually transmitted infections and to improve the outcomes of people with HIV by ensuring early diagnosis. It also seeks to tackle prejudices and to protect children from abuse.

The Scottish Government launched its latest sexual health framework in 2011, setting out a four-year plan to reduce blood borne viruses, STIs and unintended pregnancies. It also seeks to encourage more positive attitudes towards sexual health and to reduce inequalities.

GPwSIs might find themselves working in a variety of settings, whether in their own practice, a community hospital, as part of non-statutory agencies (i.e. NHS walk-in centres, health promotion units, units within an NHS trust) or other primary care setting.

Typical clinical services provided by a GPwSI might include:

• Provision of all forms of contraception including LARC (long acting reversible contraceptive) methods
• Managing contraceptive problems and providing contraception for women with medical problems
• Assessment of, and screening for, STIs and blood borne viruses
• Involvement in proactive STI control, i.e. disease screening
• Reducing sexual health inequalities by ensuring services are available for at-risk and vulnerable groups
• The delivery of psychosexual care
• Offering tests and treatment for STIs in men and women, as well as groups with special needs such as young people and injecting drug users
• Training others in the competencies required for providing LARC, complicated contraception and provision of sexual health services providing support for local practices in contraception and sexual health.

With the advent of GP commissioning, there may be increased opportunities for GPwSIs in England to forge a career solely in sexual and reproductive health, bidding for contracts in provision of specialised contraception or similar services.

Useful links:

• Faculty of Sexual and Reproductive Healthcare - http://www.fsrh.org

• Medical Foundation for Aids and Sexual Health (MedFASH) - http://www.medfash.org.uk

• British Association of Sexual Health and HIV www.bashh.org

• HIV Pharmacy Association www.hivpa.org

Q&A Jenny Brotherston, GPwSI Sexual Health and Women’s Service, Hull

What attracted you to a career as a GPwSI in sexual and reproductive health?

I have always been interested in both sexual health and women’s health. I had considered a career in gynaecology but I wanted to start a family before I was 30 and at that time the GP career route was better suited to part-time completion than hospital training.

During my GP training I achieved DFFP (now DFSRH) and DRCOG and worked in evening family planning clinics as a community medical officer. Once I qualified, I also took on the role of clinical assistant in menopause at Hull Royal Infirmary and then staff grade doctor in a GUM clinic. I became accredited as a GPwSI sexual health in 2004.

What do you enjoy most about the job?

Being a GPwSI means that I can offer a truly holistic service to my patients. No other model of clinic can, for example, offer a woman concerned about a breast lump, who has vasomotor symptoms and a recent change of partner, a breast examination alongside an STI screen and menopause management all at the same appointment.

I also enjoy being able to spend a bit more time with patients, who are often grateful that someone has finally listened and explained things to them in greater depth.

Are there any downsides?

The seeming dichotomy of a generalist becoming a specialist has sometimes left GPwSIs unsure of their position among consultant colleagues. As time goes by, however, and especially now that the FSRH and the RCGP are working so closely together, I feel the role of the GPwSI is becoming more established in the world of sexual health.

What do you find most challenging?

The uncertainty of the perpetual change in management structure. Since becoming accredited, my employing organisation has changed twice and, with the new NHS structure, we have to re-tender our own service at the end of this year.

What about the role has most surprised you?

Three GP colleagues and I set up the GP specialist sexual health and women’s service in an area of high deprivation, teenage pregnancy and chlamydia rates, with few female GPs. We offer contraception, GUM, community gynaecology and menopause care all at one appointment. The surprise is that I’ve been successful in developing an enduring service that survives all the changes that happen around it. I didn’t know I had this entrepreneurial side.

What is your most memorable experience so far?

Teaching has always been an important and rewarding part of my role as a GPwSI. Following a conference that I organised and presented at last July, I was sent a draft dissertation a local GP had written for a postgraduate medical education certificate. He had chosen to use the example of my lecturing style, comparing and contrasting with another disappointing lecturer, to illustrate the value of the traditional lecture in the hands of a skilled educator. It cannot be often that one receives such an accolade as to be chosen as the subject of a dissertation!

What advice would you give to a trainee GP considering a career as a GPwSI sexual and reproductive health?

Trainees have more opportunities open to them now. There is a new career route to become a consultant in sexual and reproductive health directly with FSRH. To work in sexual health alongside general practice, I would advise studying for DFSRH and the STIF competencies. CCGs are also working with the RCGP to review the standard setting for GPwSIs in sexual and reproductive health.