A national audit of the management of young people in genitourinary medicine clinics (level 3 services) in the United Kingdom

Introduction

A British Association for Sexual Health and HIV (BASHH) national guideline for the management of young people in genitourinary medicine (GUM) clinics was first introduced in 2002 following a survey which demonstrated that written policies were lacking and that there was a need for training. ¹ A subsequent survey in 2004 showed improvements but concluded further training was needed. ² In 2010, the guideline was updated. ³ This is the first national audit which examines case notes and individual care against the standards recommended in the guideline: offer of screen (standard 90%), acceptance of screen (90%), completion of risk assessment proforma (100%) and following a guideline (100%). The guideline provides a suggested risk assessment proforma as an appendix. This audit also examines whether use of a proforma is actually associated with better assessment.

Methods

The project was designed by a working group of Specialty and Associate Specialist (SAS) doctors in GUM. Data collection questionnaires were developed by iteration and piloting by experienced clinicians. The questionnaires used are available on the National Audit Group page of the BASHH website. ⁴ Doctors on the BASHH SAS database were invited to participate, nominating local coordinators to lead the project at participating clinics. Doctors submitted data for patients aged 13–15 years who attended in 2011.

Results

The invitation to participate was emailed to 539 doctors, of whom 173 (32%) submitted data. Doctors in 73 level 3 GUM clinics participated, submitting data for 2018 patient episodes and information on their clinic policies. Of these clinics, 68 (93%) follow a guideline and 68 (93%) use a risk assessment proforma for consultations with young people. Case note examination found that 1732 (82%) patients were assessed using a young people’s proforma. When a proforma was used, the completion rate of records relating to four characteristics was higher (Table 1). Most episodes (1946, 92%) involved young people who had been sexually active, and who either had never had testing for sexually transmitted infections or who had risk of infection since their last tests. Of these, 1871 (96%) were offered tests, of which 1692 (90%) accepted. Where a proforma was used, acceptance of testing was slightly higher (97% of eligible patients were offered testing, of whom 91% accepted) than where no proforma was used (93% of eligible patients were offered testing, of whom 89% accepted).

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Table 1.

Record completion with and without use of proforma.

Risk assessment record field a	Number (%) recorded a where a proforma was used (n = 1732)	Number (%) recorded a where NO proforma was used (n = 362)
Mental health	1147 (66)	72 (20)
Alcohol consumption	1474 (85)	126 (35)
Drug use	1506 (87)	161 (45)
Domestic circumstances b	1576 (91)	114 (32)

Discussion

There were 279 clinics on the BASHH national audit register at the time of invitation. A clinic participation level of 73 (26.2%) seems low. However, clinics could not participate if there were no SAS doctors in the staff team or if they did not see under 16 year olds. Some clinics are satellite services of main clinics and submitted data as a group under one name. The number of patient episodes submitted was considerable and compares well with a previous national SAS doctors’ audit. ⁵ The sample was not randomly selected, in common with usual practice in audit. Data were submitted from clinics in England, Wales and Scotland and from at least one clinic in every BASHH region except Northern Ireland.

Standards were met on offer and acceptance of tests. A high proportion (93%) of participating clinics follow guidelines (either the BASHH guideline or a written guideline based on it), but the standard of 100% was not met. The use of a proforma was frequent and improved assessment, but the standard of 100% use was not met. The proforma is designed to highlight young people who are experiencing or vulnerable to abuse or exploitation, prompting questions about characteristics such as a history of mental health problems, drug or alcohol use, school absence, non-consensual sexual activity and other factors. The information obtained can then inform decisions about child protection or referral to other agencies to safeguard and support the young person. Rate of referral was not examined in this audit. It would be useful to consider adding this to any future audit.

The BASHH guidelines strongly advise the use of a proforma and this audit supports that guidance, notwithstanding the fact that these are observational findings in a non-randomised sample. The results are in keeping with other audits that support the use of proformas. ⁶ Clinics where a proforma is used may have better general awareness and training and a higher level of motivation to make good assessments of young people but the use of a proforma was apparently associated with better record keeping. Therefore, introduction at those clinics not currently using a proforma, along with a training and launch process, is the main national recommendation.

A high standard of assessment should increase the likelihood of identifying young people at risk, thereby offering an opportunity to intervene and support vulnerable young people who attend for care.