Abstract
Sir: We read with interest the Chelsea and Westminster NHS Foundation Trust's patients and staff questionnaires study on Patient–Delivered Partner Medication (PDPM). 1 We observe that the authors have considered the ‘unlawfulness’ of the proposal and had discussions with the chief medical officer regarding the issue. We have also received a similar questionnaire on PDPM, which appears to be part of a national survey. The article has made a case for PDPM, on the basis of patient and staff majority opinion. More than likely, the national survey will share similar findings. The idea has also received favour in the eyes of gynaecologists, doctors in family planning, general practitioners, practice nurses and pharmacists. 2 Several studies examined the approach, with some favourable observations;3,4 with an Ugandan study reporting more effectiveness than patient-based partner referral. 5 The idea was explored some 10 years ago, 6 and would entice many, for the obvious advantages that are cited by the authors. We wish to examine the issue closely and deeply, with the following observations:
PDPM will send the wrong emotive message to both patients and the wider medical community. It trivializes the acquisition of sexually transmitted infections (STIs), in the minds of patients, to a condition of ‘remote treatment’ without the need for tests. It is a step on a slippery road towards providing treatment without investigations; a concept that has repeatedly surfaced on the minds of primary care trainees attending genitourinary (GU) medicine clinics: ‘what is the broad spectrum antibiotic for STIs?’ The idea is enforced by their routine practice of treatment for other (e.g. respiratory and urinary tract) infections, without full microbiological investigations.
Indicators from STI clinics, nationally and internationally, show that patients who have one STI condition need other STIs to be excluded. 7 PDPM will undermine the concept of excluding other STIs. We observed that some proponents of PDPM could have missed 19 HIV, 61 syphilis, 133 PID and 72 gonorrhoea cases if they had not provided tests for the partners of the index cases in their study of 8623 individuals attending four sexually transmitted disease clinics. 3 This is of special relevance when we are warning the public and the medical establishment that one third of HIV patients remain undiagnosed. 8 Double and conflicting messages are confusing, and undermine the credibility of our clinical care.
Not all contacts of patients who are chlamydia positive have chlamydial infections. One in four patients will have unnecessary treatment, if PDPM is offered. 9 It is true that GU medicine clinics offered epidemiological treatment for patients, but this was part of a process of clinical and laboratory investigations and at a time when test sensitivity was not equivalent to what we have at present. Patients who had epidemiological treatment then had tests to exclude other STIs and were offered follow-up care. The unnecessary handing of antibiotics is unjustifiable.
PDPM will undermine the direct ‘one-to-one discussion’ that is a pivot of STIs prevention. The recently published NICE guidance on sexual health (SH), rates staff-patient interaction highly. 10 PDPM will circumvent the opportunity for education on SH.
NICE advised that partner notification, testing and treatment should be the model of care. 10 The health care cost in this case is an issue of interest but should not circumvent appropriateness, quality, consistency and equity in clinical care. PDPM falls below NICE standards.
The repeated, unnecessary and undocumented use of antibiotics will have implications on microbial resistance for other incidental organisms (not necessarily chlamydia) and eventually reflect on microbial resistance of community based and hospital infections. Our experience with patients’ repeated and recurrent STIs should not be ignored. With PDPM, a patient may receive multiple antibiotics from different partners.
Some pharmacists in European countries dispense antibiotics over the counter and the idea will spill over to UK legislations. Pharmacies in England have been providing chlamydia testing kits. The combined effect translates to the free and potentially repeated use of antibiotics, without any documented patients’ medical records. PDPM for the above reasons, fall below good GU medicine practice, as indicated by a body of clinical expertise and research findings.
The General Medical Council's (GMCs) good medical practice is not only a matter of medical legislation but also a collective evolution of an immense body of medical experience, clinical care and public interests. It draws on a long and wide history of clinical care and withdraws from the collective expertise of medical professionals and representatives of the public. It refers to ‘prescribing in the patient's best interest’;
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with the following advice to doctors:-
Be in possession of, or take, an adequate history from the patient, including: any previous adverse reactions to medicine; current medical conditions; and concurrent or recent use of medicines, including non-prescription medicines. Establish the patient's priorities, preferences and concerns and encourage the patient to ask questions about medicine taking and the proposed treatment. Discuss other treatment options with the patient. Satisfy yourself that your patient has been given appropriate information, in a way they can understand, about: any common adverse side-effects; potentially serious side-effects; what to do in the event of a side-effect; interactions with other medications; and the dosage and administration of the medicine. Satisfy yourself that the patient understands how to take the medicine prescribed. Satisfy yourself that the patient is able to take the medicine as prescribed.
The GMC guidance has a special reference to ‘remote prescribing' 11 that deals with other non-face-to-face medium, to prescribe medicines and treatment for patients. The GMC advises that:
You have responsibility for the care of the patient.
You have prior knowledge and understanding of the patient's condition/s and medical history and you have authority to access the patient's records.
In all circumstances, you must ensure that you have an appropriate dialogue with the patient to ensure the above criteria.
PDPM does not meet any of the standards or conditions listed by the GMC.
In summary, PDPM falls below clinical standards, clinical governance and good medical practice.