Provider and contract
referral for bacterial
STIs: two sides of the
same coin?
Exploring the clinical practice and attitudes
of sexual health advisers
Merle Symonds
on behalf of Spread the Word team
Partner Notification in UK
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Partner notification a core element in STI control
Shift in STI testing and management from GUM to
primary care settings
Emphasis on ensuring that all services offering STI
screening are competent in all aspects of
patient/partner management
Growing body of research exploring efficacy and cost
effectiveness of partner management strategies
Why commission research
on PN?
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The National Chlamydia Screening Programme (NCSP)
was identifying a new population requiring PN
Recent NICE guidelines on one-to-one interventions for
sexual health identified need to enable PN in community
settings
Evidence review for NICE on partner notification
Emergence of new technologies may reduce efficacy of
existing PN practices or offer scope for improvement
HTA call (07/43) with outline submission in summer 2007,
for a randomised controlled trial of partner notification
(contact tracing) in primary care
The brief from HTA
Spread The Word
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Three arm, randomised controlled trial(RCT) of PN
among patients diagnosed with Chlamydia in general
practice.
 Routine (patient),
 Provider
 Contract referral
Webtool linking participating GP study sites with a
central research health adviser (RHA) office
RHA conducts standardised PN activity relating to
patients and partners according to trial arms.
Outcomes measured include total partners notified,
diagnosed, treated, reinfection rates, economic
evaluation
Spread The Word
Partner notification (PN) is accepted
as an essential element of STI
control.
Index patient benefits
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Reduces index case risk
of complications due to
reinfection (chlamydia)
Public health benefits
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Reduction of onward
transmission
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Targeted testing has
high yield
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50% chlamydia contacts, 65%
gonorrhoea contacts will test
positive
By contrast, 3% of a population
sample will test positive
Partner Notification
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Patient, partner, passive or self-referral
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Provider or active referral
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Conditional, contract or negotiated referral
Faldon.C et al. The Manual For Sexual Health Advisers
(SSHA 2004)
Patient, partner, passive or
self-referral
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Denotes when the index patient with the infection informs
sexual partners. They are encouraged to notify partner(s)
of their possible infection without the direct involvement of
a health adviser. The patient may:
 Provide the partner with information
 Accompany the partner to the clinic
 Hand over a contact slip
The health adviser may help a patient to establish the
information to be passed on to a partner and the methods
of providing it.
Provider or active referral
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A health care worker notifies a patient’s partner(s). In
the UK health advisers in GUM clinics almost
exclusively perform this.
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The index patient provides information on partner(s) to
a health adviser, who then confidentially traces and
notifies the partner(s) directly.
Conditional, contract or
negotiated referral
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A hybrid approach may be employed where an initial
patient referral is followed up by a provider referral after
an agreed period of time, if the contact has not
attended.
What the SSHA Manual
doesn’t tell us….
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How are these partner notification models
operationalised in clinical services in the UK?
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What is the role of contract referral in current
practice?
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Need for greater clarity in order to develop distinct,
operational trial arms
Developing Spread the
Word trial interventions
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Pragmatic PN study
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Trial interventions should be representative of current
PN practice
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Reproducible in clinical practice
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Individuals experienced in conducting PN should be able
to distinguish clearly between the three trial arms
Questions to be answered
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Are the three PN methods clear to HAs from a variety of
service types?
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Are the three PN methods feasible and operational?
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What are the patterns of use for each arm?
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Are there conflict between theory and practice, and if
so, how can they be resolved in a standardised
intervention?
Engaging the experts
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Capture the experience and attitudes of health care
workers conducting PN in a range of service settings
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Ascertain a clearer picture of how partner notification
models are operationalised in clinical practice
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Seek health adviser views on the proposed trial arm PN
models
Methods
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Email invitations to 12 sexual health advisers/health
practitioners to participate in a one day focus group
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Participants sought on basis on diversity of role/service
setting
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Metropolitan GUM clinic
Rural GUM clinic,
Integrated CASH/GUM/CSO,
Community health adviser
Acute teaching trust, Acute trust, PCT
Methods
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Participants completed an online questionnaire prior to
the focus group to establish baseline information on:
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Experience
Service setting
Establishment
Responsibility for PN
Local PN policy/standard operating procedures
Use of patient/provider/contract PN
Training/education/competency measurement
Methods
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Focus-groups:
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participatory approach, utilising role play of commonly
occurring clinical scenarios with actors playing the role of
patients diagnosed with infections, observed by
participants and facilitated by study team
Facilitated discussion of experience of partner notification
in clinical practice
Trialling of trial interventions/proposed models
Data collection: 7 hours of audiotaped material transcribed
and thematically analysed
Participants
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Ten sexual health advisers/practitioners from nine services
from across England (5 metropolitan, 5 non-metropolitan)
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Six female participants, four male
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Participant experience of delivering PN ranged from two
years to in excess of twenty
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Five participants had current/previous experience in
senior/management roles, including training/supervising PN
practice
General approaches to PN
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Highly individualised
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Negotiated process
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Variable parameters include: infection type, relationship
nature and duration, sexual orientation of patients,
contact detail type and motivation to contact partner/s
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Some patterns identifiable re: practitioner’s offer of PN
choices
Patient referral
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Most of participants agree common first approach for
majority of patients.
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May include preparatory discussions to help with
managing difficult issues around disclosure and
implications especially around issues such as infidelity
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Individual views on what is ‘best’ for the patient may
also influence PN negotiation
“I suppose on the first offering [it’s about] reading how they
feel about letting someone know, really, and getting a feel.
But I would like to give people the opportunity to refer
themselves [patient referral]. I think the outcome is better for
them”
Provider referral
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All participants use provider referral, but how and when
offered is variable
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Many participants reported making calls to partners as
soon as information is received from patients,
sometimes within the team, sometimes with negotiation
with external clinics
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Some participants choose to offer provider referral on
basis of perceived improved outcomes
“The PN we offer is very much dependant upon the
condition [diagnosis] of the patient. Mostly we favour a
provider referral just to take on ourselves and hopefully its
going to get a better outcome as a result…Index patient
referral, we generally try not to…and that generally seems
to be the better one that the staff and patients prefer”
Provider referral
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Participants highlighted that infection and patient types
are significant in whether provider referral is offered or
not.
“The provider referrals, I think are by far…this is also an
urban [metropolitan] clinic, so by far the preferred…I
actually tend to do those more for the blood borne
infections, particularly with MSM. HIV is one that I’m much
more likely to engage that.”
Provider referral
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Some participants articulated the conducting provider
referral resulted in an improved sense of satisfaction
with one’s work/role
“I wouldn’t say that the culture of my clinic was necessarily
provider referral. That’s for me….because I know that I
can get everything done. Having done the gay men’s
clinic for quite some time in various long spells, and that’s
where the vast majority of provider referrals come from.
You’re talking 20 or 30 people per patient. And it’s me.
Yeah, it becomes a mission, actually. I start making charts
of them all. So yeah, there’s some personal difference
and I think that’s experience."
Contract referral
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Participant’s accounts of contract referral use in clinical
settings, and their own experience was variable
“The only time I know that’s been used in my clinic has
been around HIV patients and usually that process has
begun as generated by the HIV team staff, so everyone
has got a hand in it”
“We do when there's a fragility, a psychological vulnerability
around the impact of that diagnosis. But I can sense that
actually it's important that they do tell their partner, they want
to tell their partner but... just can't quite work it out at this
point and they need more time to absorb it and think about
it.... you can see that they're processing something and it's
not the same as they're being resistant but actually just
trying to work out how they're going to navigate it and
negotiate it. So often I will say to them, 'Well, why don't we
set a timeframe here and maybe buy like two or three weeks.
If I follow you up, maybe by that point you'll have got to this
stage,' and then I follow them up”,
Ambiguity in PN
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Participant interpretations of what constitutes contact
referral varies
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The notion of contract referral being an implicit part of
the PN process rather than something formally agreed
between clinician and patient was highlighted by a
number of participants
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For others participants this is not considered as Contract
referral but part of routine follow up care
“I think if they rang back and they were...I know we talked
about Provider referral, but I think I would prefer to do an
Index patient one, then I would say, 'That's fine.' And I'd
asked them what had made them change their mind... and
then I would probably turn them over to maybe a Contract
and say, 'I'll give you two weeks. See how you get on and
then I'll give you a call,' and frame it that I was just
checking to see how they were getting on. And then if
they'd been able to do it, then good. If not, then I think I
would say maybe, 'It's not too late to go back to a
Provider.”
“...we tell all our patients that we will call them in a couple
of weeks' time just to see how they are and we wrap it
round saying, 'Did you have any problems after the
tablets? Were you okay?' ...But we always tell them [in
advance] and say, 'And then we can see how you're
getting on with telling your partners.' So, in a way, the
Contract referrals are implicit in the normal way that we
work because of the checking we do at two weeks. If they
haven't been able to do it then, then we'll [offer Provider
referral]”.
“You usually know quite soon if they're happy to let an
individual know. Or they might be happy to let one know
and not quite sure about another one. So for me, it's one to
one with that individual. And also you kind of know if
they're telling the truth to me and so everyone would be
followed up and it's on that follow-up call for, say,
Chlamydia, two weeks down the line, to actually talk to
them and...re-assess the situation. If then they've had
problems you do Provider referral”
Negotiated referral
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A number of participants took partner names as a basis
to aid follow up, no participants routinely documented
contact details for partners at initial consultation
A theme of negotiated referral emerged from
participants, giving patients time to think or weigh up
options re: patient referral.
Within this an offer of delayed provider referral as part
of a follow up call within a negotiated timeframe, with
partner contact details being taken at follow up, if the
patient was unsuccessful in contacting partners
Implications for the Spread
the Word trial
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Outcomes from the focus group show only two distinct
models of PN
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Patient referral
Provider referral
Two arm RCT
Recalculated sites/index patients
Implications for PN practice
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PN models are in practice fluid though the process of
PN
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High degree of variability in how PN is operationalised
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Existing guidance though widely recognised, is
ambiguous and confused in it’s interpretation and may
well need to be amended to reflect difference in practice
between bacterial and blood borne infections
Implications for PN practice
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Absence of any qualitative operational research of PN
practice
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Data shows demonstrates a rich and dynamic process
between professional and patient
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However this needs to be more clearly articulated to
enable reproducibility and measurement of competency