Abstract
Genitourinary Medicine (GUM) is a specialty that has undergone significant change over the past decade. Multiple factors have contributed to this including changes in service models and commissioning landscapes, health service leadership, medical education and changes in the spectrum of our clinical work. The Joint Specialist Committee for GUM at the Royal College of Physicians (RCP) conducted a national survey in December 2019 – January 2020 to understand the changing scope of work for GUM consultants. The survey indicated an increase in clinical complexity alongside a decline in registrar recruitment, staff shortages and service fragmentation. Funding cuts have impacted many services and the majority of consultants feel a return to an NHS commissioning model would be preferable. Despite the many challenges, GUM physicians consider the specialty ‘unique, dynamic, friendly and open-minded’. It is clear that senior doctors value the wider clinical, academic and educational opportunities within the specialty.
Introduction
Genitourinary medicine (GUM) is a speciality that has undergone significant change over the past decade. Multiple factors have contributed to this such as changes in service models and commissioning landscapes, health service leadership, medical education and changes in the spectrum of our clinical work including the prognosis and models of care for people living with HIV.
The specific role of a GUM consultant is at times unclear, and many consider the name of the speciality does not accurately describe the remit of our work. This may be why so many consultants trained in GUM choose other titles such as ‘Sexual Health and HIV’ and confusion can result for those not directly involved in our services and training pathways.
The Joint Specialist Committee (JSC) for GUM at the Royal College of Physicians (RCP) developed a national survey to understand the changing scope and complexity of work for GUM consultants. We aimed to capture the current working conditions of senior physicians, identify issues that might be affecting recruitment and consider our future direction. Questions explored the impact of the 2012 Health and Social Care Act in England, competitive tendering of services, the challenges we face, the most satisfying aspects of our role, how we identify ourselves as a speciality and whether we should seek to be renamed.
JSC survey: ‘The changing role of the consultant in GUM’
The survey was open from the 13th of December 2019 to the 14th of January 2020. Hence, data were collected prior to the Covid-19 pandemic, which started to impact services significantly from March 2020. It was disseminated to doctors on the General Medical Council specialist register in GUM via the British Association for Sexual Health and HIV. There were 272 responses in total; RCP workforce data indicate approximately 400 doctors would have been eligible to participate; hence, there was good coverage (68%) for a survey of this kind.
Demographics
Overall, 90% (n = 243 of 271 respondents) were based in England; therefore, the vast majority would have been affected by the tendering and commissioning processes introduced from 2012 (Figure 1). In total, 65% (n = 176 of 271 respondents) were female, and there was approximately a 60:40 percentage split between full and less than full time consultants, respectively. This is compatible with workforce data indicating feminisation of the speciality with many women taking career breaks and working less than full time. Although a large number of consultants are in the early/middle stages of their career, many (31%) are older (n = 84 of 270 respondents were aged 55 and above). Demographics of survey respondents.
Key survey results
The survey revealed that GUM consultants are spending 61% of their clinical time on complex cases, with the majority (73%, n = 154 of 210 respondents) feeling complexity had increased in the past 3 years. Increased complexity was attributed to both clinical and service-related changes. Clinical reasons include managing an ageing HIV cohort with multiple co-morbidities, increasing prevalence of complex sexually transmitted infections (STIs) such as syphilis and antibiotic-resistant infections, contraception provision in integrated consultations and multi-agency safeguarding. Service-related changes include more efficient triage systems to direct complex cases to doctors, increased patient demand and increased specialist referrals from primary and secondary care plus staffing cuts forcing more clinical role overlap. The changing case mix has increased the intensity of work overall.
Due to clinical service pressures, a large number of consultants spend unremunerated time on supporting professional activities (SPA), academic roles and additional clinical work (Figure 2). This seems to be consistent with the national picture across most medical specialities. The RCP published a census in 2018 entitled ‘Focus on physicians – Census of consultant physicians and higher specialty trainees’.
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It estimated that ‘consultants worked on average 10% more than they were contracted to do’. However, it is worth exercising caution when comparing the census data with our survey data as there are key disparities; the census is from 2018, had a lower response rate (37%) and is reported in overall additional hours worked rather than a range. Number of hours spent on direct clinical care, SPA and additional NHS responsibilities above remunerated activity in a typical week. DCC: Direct clinical care; SPA: Supporting professional activities; ANR: Additional NHS responsibilities; Academic PAs: Academic programmed activities.
We identified that 83% (n = 155 of 187 respondents) of UK consultants feel the transfer of sexual health commissioning responsibilities to local authorities in England has not been a positive move for the speciality. Clinicians cite cuts in funding and resources as an important but not the only issue. 2 Other issues include the need to make very challenging and at times unfavourable service delivery decisions, fragmentation of services, difficult competition between colleagues and services, experiences of instability and job insecurity and being pulled away from service delivery to work on tender bids. This instability and funding cuts may deepen as some local authorities report potential bankruptcy due to the impact of the Covid-19 public health crisis. 3
There is also an impact from the tendering and commissioning process on training and wider professional development. A recent paper highlighted the negative impact on postgraduate training and national figures show significant and sustained decline in recruitment with just 26% of advertised higher speciality training posts in GUM being recruited to in 2019.4,5 In addition, some reflected that the new commissioning arrangements ‘lack an understanding of the bigger picture’ and do not adequately value training, research or work for national bodies.
Overall, 79% (n = 146 of 185 respondents) of consultants feel the speciality would benefit from a move back to a NHS commissioning model, 3% (n = 5) supported the current model and 18% (n = 34) did not express a preference. Many feel the NHS model would provide ‘clearer boundaries and service requirements’, an understanding of clinical complexity and reduce the national variability in commissioning. Opinion was strong that, as a medical speciality, GUM belongs in the NHS and that cohesive working with wider medical specialities is central to safe patient care. There was notable support for commissioning ‘within a pure health framework’ and not alongside non-clinical services in local authorities. Clinicians also felt ‘training, education and standards would be prioritised in an NHS commissioning model’ as these areas are already integral to the organisation as whole.
Clinical practice has changed and 72% (n = 131 of 182 respondents) feel ‘GUM’ does not accurately describe the current remit of clinicians and only 53% (n = 96 of 182 respondents) use this in their working title. Most (80%, n = 145 of 181 respondents) feel the speciality should be renamed with 92% (n = 146 of 158 respondents) favouring ‘Sexual Health and HIV Medicine’ as an alternative. This name is perhaps a better reflection of working practice within a physicianly speciality, especially with impending dual accreditation of trainees in both GUM and internal medicine from 2022.
Despite the many challenges encountered over the past few years, GUM consultants still largely enjoy their roles. Almost all cited direct patient contact, ‘reducing stigma and inequalities’ and ‘making a difference’ as positive aspects. In addition, ‘dedicated and supportive colleagues’, work–life balance, clinical diversity and holistic care were highly valued. As a speciality, physicians consider GUM to be ‘unique, dynamic, friendly and open-minded’. It is clear that senior doctors really value the diverse clinical, academic and educational opportunities within the speciality.
The future of GUM: Our next steps?
The influential Parliamentary cross party Health and Social Care Select Committee published a report in June 2019 setting out key recommendations for the government and national health agencies to act upon. 6 These include developing a new national sexual health strategy, reversing budget cuts, improving recruitment and prioritising STI prevention. In February 2021, the Department of Health and Social Care published a white paper entitled ‘Integration and Innovation: Working together to improve health and social care for all’. 7 This paper contains proposals for a new ‘Health and Care Bill’ which promotes collaborative working, commissioning and provision of services by the formation of integrated care systems (ICSs) and aims to reduce fragmentation, unhelpful competition and the requirement for tendering of healthcare services. If fully implemented, this could start to address the many concerns highlighted in our survey.
However, it is clear from GUM consultants that significant damage has already been experienced by the speciality since 2013 with wide ranging implications across the board. The survey showed that many clinicians in England feel that remaining within a local authority commissioning framework will continue to negatively impact the speciality.
Now is an important time for GUM to address its place within medicine. Open communication and collaboration with allied specialities, such as Sexual and Reproductive Healthcare (SRH) and Infectious Diseases (ID), is imperative to working together whilst appreciating key differences in the scope of practice. As our survey demonstrates, GUM physicians manage increasingly complex patients. It is vital that the speciality is valued in integrated sexual health services as consultants bring unique expertise to the service. The speciality is also strongly aligned to its physicianly roots and will welcome its first dual accredited trainees in 2022 as part of the new ‘Shape of Training’ programme. 8 This will be of huge benefit to the holistic management of an ageing HIV cohort and contribute positively to the wider hospital community. By promoting our repertoire of work, specialist skills and innovative ways of working, GUM can hopefully improve recruitment and cement its key role within general medicine and public health.
In the midst of a global pandemic, there has been a truly valiant effort from the speciality to pull together, share information and contribute to the national public health effort. A similar effort is now needed to look closely at our role in medicine, our place in the commissioning landscape, our speciality name moving forward and our future as a speciality.
Genitourinary medicine has a unique role in challenging inequalities, reducing stigma and providing vital health care to vulnerable populations. We must at all costs preserve the holistic essence of our work whilst moving forward in an ever changing world.
Footnotes
Authors’ contribution
Concept of idea: MP, MK and EC.
Drafting of survey: MP, MK, EMC and SW.
Writing of article: MP, MK, EMC and SW.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
