Discussion

This paper demonstrates an interesting regional difference in the physical accessibility of GUM services. Almost 100% of the population in London and the South East have an estimated journey time of less than 30 minutes to reach their nearest clinic, while access in the South West and East of England regions is estimated to be far more problematic. So far, initiatives to make GUM clinics more accessible have concentrated on ensuring that an appointment can be obtained within 48 hours. However, this study has highlighted that in more remote areas it may be difficult for potential patients to attend a clinic due to the long travel time to the nearest site.

Although clinic access in the South West and East of England is more problematic, in 2008/2009 the data from the HPA showed these Strategic Health Authorities had lower rates of chlamydia, gonorrhoea, genital warts and genital herpes than the average for the whole of England.14 We could therefore be cautiously optimistic that the areas with greater accessibility issues are also those with lower than average STI rates and hence less demand for sexual health services. However, the data only reflect diagnoses made at GUM clinics and therefore these lower rates may not indicate a lower burden of disease in the population of these areas. Regional differences could also be due to differences in testing patterns or, as highlighted by our calculations, differences in ability to access GUM clinics. For chlamydia diagnoses, data are available for diagnoses made in non-GUM settings, but only for the 16–25-year age group.15 Taking all settings into account, these data also showed lower rates in the South West and East of England than the national average. However, the non-GUM setting data are based only on one age group and, even then, the rates of chlamydia are lower than in other regions but not necessarily low in absolute terms: 290.9 per 1 00 000 population in the East of England and 308.5 per 1 00 000 population in the South West.15 There is still a substantial burden of STI, and thus need for access to GUM services, even in the areas with the lowest rates.

Of course, sexual health services in the UK are not only provided in the GUM clinic setting. For example, the South West HPA observed that within their region a large proportion of chlamydia diagnoses are being made by general practitioners (GPs) or in clinical settings other than GUM clinics. They note that “increasing use of postal kits and provision of enhanced sexual health services in primary care reflects the regional need to reach rural populations with little access to other services”.16 A survey by the HPA in 2008 examined the provision of Level 2 sexual health services (i.e. provision of testing, diagnosis and treatment) in non-GUM settings and found that 92% of PCTs in the South West provided these services, usually at enhanced GP practices and community sexual health clinics. In contrast, only 60% of PCTs in the East of England provide such services, which is perhaps surprising given that this is the area with the highest proportion of the population living more than 30 minutes from the nearest clinic.17

These Level 2 services, including enhanced GP practices, community and satellite clinics and outreach centres, are an excellent initiative and this model might be expanded further in areas where clinic accessibility is an issue. However, the 2008 review undertaken by the Medical Foundation for Aids and Sexual Health highlighted that the quality of local services can be variable.18 Moreover, a pilot project by Plymouth Hospital GUM clinic to run additional satellite services found that “only the most basic GU medicine service could be provided efficiently in the community. Patients with more complex problems required referral to the main clinic for optimal management”.19

While the quality of many non-GUM services can be excellent, if people are seeking treatment in settings other than GUM clinics then an important investment may be in ensuring that health practitioners across all these settings have received appropriate training to deal with all aspects of sexual health and that they have the time and resources to devote to its detection and treatment. For example, a survey of GPs and nurses in Dyfed Powys, a health authority in rural southwest Wales, found that the majority were in favour of further training and support to help them manage the treatment of chlamydia infection properly.20 Following the 2008 MedFASH report, new guidelines were issued in 2010 and it will be interesting to see what the impact of these will be.21

Postal kits, such as those made available through the National Chlamydia Screening Programme (NCSP), could also be an excellent way of reaching those in more remote locations as well as those individuals who cannot or do not wish to attend an appointment. The NCSP is currently limited to those aged under 25 years and tests only for chlamydia. There are Internet-based services available that allow individuals to purchase a kit to test themselves for a range of STIs, but unlike NHS-based services these are not free and a study by Owens et al. found the testing sites were often difficult to contact with questions and that the home testing kits had poor accuracy, though mail-in kits were better.22

This study does have a number of limitations. The calculation of travel time is a measure of estimated drive time. A car's speed, and thus the time taken to complete a journey, will vary by time of day, by region and even by driver. The speeds assigned to the roads in calculating the journey times are therefore only estimates based on average speeds. The journey time also does not take into account other activities which affect the overall travel time, such as the time spent trying to park at the clinic. Nor does it represent the time taken to get to a clinic by individuals who do not have access to a car and who therefore rely on public transport. Therefore these calculations will only be an approximation of the time taken for an individual to get to the clinic and may substantially understate the true time taken by some users. It also does not take into account other barriers to access, such as the cost of travelling to the clinic or the impact of taking time off work to attend an appointment.

Comprehensive public transport data were not available for this study and it is unclear what proportion of GUM service users rely on public transport. However, several studies have suggested that it may be a substantial number, particularly among young people. A study of five clinics in the West Midlands found that 66% of patients used public transport or walked,23 while a study of service users in Southampton noted that 60% travelled to the clinic by a method other than driving, rising to 91% of patients aged under 16 years and 75% of patients aged 16–17 years.24 For those using public transport, it is likely that the times calculated in this paper represent a significant underestimate, though it is impossible to say by how much.

It may be that the perception of remoteness varies by area. People living in especially rural locations may be used to travelling long distances to access all kinds of services and therefore the prospect of a 40- or 50-minute journey to reach the GUM clinic might not seem daunting to them. For example, this study has highlighted that access in the area surrounding the Plymouth clinic may be problematic, with many users having to travel more than 30 minutes. However, if people living in the areas surrounding Plymouth are used to having to travel more than 30 minutes to get petrol for their cars or to visit their nearest supermarket, then the time taken to get to the clinic might not be off-putting.

Not many studies have examined clinic accessibility within a UK context. One which did examined the accessibility of a clinic in Plymouth. It found that 20% of users reported travelling more than 30 minutes to reach the clinic and only 69% reported that they found the clinic location, Derriford Hospital, “convenient”.25 This suggests that longer travel times might not be relative, and that the time taken to travel to the clinic might be off-putting to some potential patients. In addition, the potentially long journey times may impact the ability to reach key groups. In the Southampton study, just 2% of young people stated that they were prepared to travel more than 30 minutes to access sexual health services.24

It is vitally important that individuals have access to appointments at GUM clinics as quickly as possible. This study in no way wishes to detract from the substantial efforts that have been and continue to be made to ensure that the 48-hour waiting time is met across the country, nor from the efforts made at the local level to provide high-quality services in a non-GUM clinic setting. Patients have a number of options when seeking sexual health screening and treatment and it is likely that the proximity of a clinic to an individual's home is an important consideration in deciding whether or not to attend a GUM clinic. It therefore is important to consider geographical accessibility when planning how STI services will be delivered at the local level in order to ensure that everyone has access to high-quality sexual health services.