The publication of Standards for the management of sexually transmitted infections (STIs) under the auspices of the British Association for Sexual Health and HIV (BASHH)¹ is timely considering the increased rates of STIs across the UK over the past few years.² 

The standards, which are endorsed by the RCGP, include best practice for diagnosis and treatment of STIs. They also cover commissioning issues such as the structure of STI treatment services.

What are the implications of the standards for general practice? The standards are explicitly aimed at commissioned services and provide a clear framework for both commissioners and practitioners when devising and negotiating local enhanced services for sexual health that incorporate STI care. They give clear guidance on the minimum criteria that constitute an STI check and on the diagnostic tests that should be available to the practitioner. 

Links to other services, with clear and explicit care pathways, will need to be an integral part of any local enhanced service, including participation in a sexual health clinical network. Patients will also have to receive their treatment free of charge as they would do in a GUM setting. All of this should help to prevent local enhanced services being seen as second best or provision on the cheap. Suitable and adequate funding arrangements will need to be agreed and in place at the start of any local enhanced service.

There are implications from the standards for the generalist who has patients presenting with genital symptoms or STI risk in their surgery. In this setting, a more pragmatic approach to their use needs to be adopted and the holistic nature of general practice taken into account. For example, not every patient under 25 with vaginal discharge presenting to a GP is at risk of STIs. 

Additionally, the provision of excellent contraceptive advice to patients being managed for STI symptoms in general practice is an important role not recognised in the standards.   

Despite this, the standards do offer opportunities to improve care in routine practice. Involvement of primary care in the development of care pathways and in sexual health networks will help to clarify which patients can be managed in the practice and who needs referral. 

Training for generalists in sexual health is being addressed by the RCGP and the DH through the GP curriculum and measures such as the RCGP Introductory Certificate in Sexual Health.

Importantly, the standards clarify a number of other issues such as the need for access to gold standard diagnostics tests.  This makes it difficult to justify excluding general practice from access to nucleic acid gonorrhoea testing. The inclusion of an HIV test (along with chlamydia, gonorrhoea and syphilis tests) in the minimum STI screen is an important reminder for primary care not to overlook HIV testing. Despite exhortations from the CMO to offer more HIV tests, testing in primary care is woefully infrequent even where there are clinical indications.  

Partner notification is another thorny issue that can no longer be ignored. Local solutions need to be established such as access for GPs to health advisers in GUM or funding for practices to carry out the work.

General practice needs to digest the standards and be willing to acknowledge where care could be improved in day-to-day practice. The standards will also help GPs to make sure that sexual health services commissioned in primary care are adequately resourced to ensure adherence to them. 

Our GUM colleagues need to accept that a pragmatic approach is sometimes appropriate for particular patients, some of whom would never approach a GUM clinic even if referred.