Background and methodology Lengthy waiting times can be a major problem in walk-in sexual health clinics. They are stressful for both patients and staff and may lead to clients with significant health issues leaving the department before being seen by a clinician. A self-triage system may help reduce waiting times and duplication of work, improve patient pathways and decrease wasted visits. This paper describes implementation of a self-triage system in two busy sexual and reproductive health clinics. Patients were asked to complete a self-assessment form on registration to determine the reason for attendance. This then enabled patients to be directed to the most appropriate specialist or clinical service. The benefits of this approach were determined by measuring patient waiting times, reduction in unnecessary specialist review together with patient acceptability as tested by a patient satisfaction survey. The ease of comprehension of the triage form was also assessed by an independent readers' panel. Results IntroductionSexual health care is deemed by the Department of Health to be a key priority for the National Health Service (NHS). In November 2004, the Public Health White Paper 'Choosing Health' stressed the importance of modernising NHS sexual health services with an emphasis on easy access to testing and treatment of sexually transmitted infections (STIs). 1 Southwark, in South London, is an area with one of the highest prevalences of STIs, teenage pregnancy and abortion in the UK. 2 In 2004, when this study was initiated, the age-standardised abortion rate in Southwark was 46 per 1000 women, compared with 17.8 per 1000 for England and Wales. 2 In order to improve access to STI health care, family planning clinics in Southwark also began testing and treatment of common genital infections. This has led to a significant increase in workload, creating a challenge in managing these patients without reducing the quality of care received by those attending clinics for contraception. During 2003During -2004, the total number of clinical consultations increased by 24% (from 15 370 to 19 051).For many years these clinics had been operating a walkin, open-access system, which was thought to best meet the needs of the local population. The increasing demand, however, had an impact on the waiting time in the clinics, with increasing patient dissatisfaction. assigned to the 'traditional treatment' arm, with patients at subsequent clinics being assigned to the 'self-triage' system. Waiting times were collected by the receptionist and clinic staff. Ninety six patients followed the traditional route, 97 the new self-triage system. Sixty-nine (35.8%) patients completed the satisfaction survey. The self-triage system significantly reduced waiting time from 40 (22, 60) to 23 (10, 40) minutes [results expressed as median (interquartile range)]. There was a non-significant reduction in the proportion of patients seeing two clinicians from 21% to 13% (p = 0.17). Satisfaction levels were not significantly altered (...

Changes to sexual health clinics have recently been driven by government waiting time targets. However, patients' needs and expectations should be equally important when making service alterations. This study sought to determine what patients valued most when attending an integrated sexual health clinic. During February 2009, 252 patients attending a sexual health clinic in outer London completed an anonymous questionnaire. The questionnaire asked for their views on different aspects of sexual health care. The results showed that the most highly valued aspects of care were confidentiality (18.47% of points allocated) followed by speed of service (13.1%) and rapid test results (12.12%). These aspects were more important than being seen within 48 hours (7.78%), technical expertise (6.26%) or other patient-centred aspects of care. These findings, which represent patients' views, have important implications for service design.

These two papers discuss whether gonorrhoea screening of asymptomatic heterosexual men with no contact history should continue in UK genitourinary medicine clinics. Currently, most clinics routinely test all attenders. This requires an estimated 330,000 tests annually to detect 915 positives (1 in 361). The benefits to these patients are uncertain but the costs are huge and could fund currently unprovided services such as oral contraceptive provision or HIV testing before terminations of pregnancy. However stopping testing would deny individuals the reassurance they seek, prevent early detection of outbreaks and fail to detect carriers who go on to cause morbidity in their partners. On this view, the availability of non-invasive tests should be used to widen screening.

Although the 'patient provider partnership' is now supposed to be an integral part of modern clinical care, an assumption is often made by clinicians that they know what patients want from health services. Sexual health care is no different. In order to investigate the accuracy of this supposition, a survey was undertaken in February 2009 of all staff members working in the Department of Reproductive and Sexual Health (doctors, nurses and administrative staff) in Enfield. They were asked to predict what their patients' priorities were when accessing sexual health services. The results showed that nurses were the most accurate at anticipating what patients most valued, by correctly predicting their top three priorities (confidentiality, speed of service and rapid test results). Doctors were the least accurate and only predicted one of the top three patient priorities. These results are now being used locally to ensure that all members of the multidisciplinary team have input into the development of clinic guidelines and service design.

Sir,The paper by Brown et al. relating to the 'white coat effect' in hypertensive pregnancy (Vol 106, May 1999)' is interesting. The use of 24-hour monitoring with an ambulatory blood pressure monitor is not routine in all units; neither, therefore, is the accurate determination of a 'white coat effect'. We have previously noted' that around one quarter (50/204) of primigravidae had a systolic blood pressure of t 140 mmHg noted at their first antenatal visit to their general practitioner, with normal diastolic pressure, but had systolic pressures an average of 10 mmHg less than 140 mmHg at their hospital booking antenatal clinic visit. The first antenatal visit of a woman's first pregnancy is likely to be emotionally stressful, and may be unmasking labile blood pressure control. These women were an average of 18 months older and had significantly higher body mass indices at booking than women who did not show transient systolic hypertension. They were also twice as likely to develop pregnancy-induced hypertension or pre-eclampsia later in the pregnancy as the women who did not show this 'early', transiently-raised systolic pressure, in accordance with the observations of Halligan et aL3.Data on blood pressure measurements made in general practitioner clinics are highly unlikely to be standardised. Nevertheless, our sample was randomly recruited and we were unable to identify any source of systematic bias. It may therefore be suggested that an isolated 'spike' of systolic pressure at the first GP antenatal visit is a form of 'white coat effect' which can alert the clinician to an increased possibility of hypertension in later pregnancy, rather than much ado about nothing. F. Broughton Pipkin AUTHORS' REPLYSir, I agree with the comments of Professor Broughton Pipkin. The interpretation of her study' is certainly consistent with the presence of a 'white coat effect' in primigravidae at their booking hospital visit. Our study2 differed firstly in that we enrolled women in the second half of their pregnancy; these women had already had several antenatal visit and in general had been thought to be normotensive in the first half of pregnancy. Secondly, we screened these women for true hypertension by only making a diagnosis of hypertension if the blood pressure remained elevated after overnight rest in hospital or following a morning stay in our day assessment unit. In this setting which is quite different from the normal antenatal clinic visit, only 3%-4% exhibited white coat hypertension, though 20% still exhibited a diastolic 'white coat effect' which we did not find to be of clinical significance. Hence the title 'much ado about nothing'.On the other hand, we observed that 27% of pregnant women, labelled as being hypertensive on the basis of their antenatal clinic visit readings, in fact had normal blood pressure when screened in the day assessment unit. This figure is very close to that of Professor Broughton Pipkin's observations in women studied earlier in pregnancy.In an ongoing study supported by the National...