Participants by study arm
11/27 (41%) of practices invited agreed to take part; eight randomised to receive the intervention and three to the control. In control practices of 349 tests carried out during the study, 228were submitted amongst recruited patients, mean age 32 years. Excluded from the study were 121 (34.7%) patient tests: 62 patients were ineligible, 5 assigned to the incorrect study arm and 54 declined permission for use of anonymised medical records. In intervention practices of 805 tests carried out during the study, 436 were submitted amongst recruited patients, mean age 34.1 years. 369 (45.8%) patient tests were excluded from the study: 77 clinically inappropriate, 39 patients were ineligible, 238 not consented to receive NLTM and 15 were assigned to the incorrect study arm. Interviews with HCPs indicated that few patients declined consent to receive NLTM and it was more usual for the study online consent process not to be completed by the HCP due to time pressure during consultations (see ‘Discussing nurse led telephone management’ section).
1154 Chlamydia/gonorrhoea tests took place during the study period (April – September 2015), with 805 (70%) in the intervention and 349 (30%) in the control arm (Table 1). 30 tests were positive for chlamydia (positivity rate of 2.6%), and 9 for gonorrhoea (positivity rate of 0.8%). Three patients were positive for both chlamydia and gonorrhoea. The chlamydia positivity rate was slightly lower (2.0%, 95% CI: 1.1-3.3) in patients included in the study compared to those excluded (3.5%, 95% CI: 2.2-5.5). Approximately 23% (101/436) of patients who consented to receive NLTM were managed via primary care (Table 2), qualitative interviews identified that this was due to delays in data transfer to NLTM. This initial issue was resolved by the laboratory automating sending relevant patient details to the NLTM for action. In total the NLTM managed 335 patients, of which 11 tested positive.
Sixteen HCPs (11 GPs, 5 nurses) and 12 patients (8 female; ages 22-50/average 32 years; 3 positive test results; ethnicity = 10 White British/1 White other/1 unknown) were interviewed (Table 3). Eleven patients consented to NLTM and one patient was recorded as having declined NLTM but agreed be interviewed. Patients were interviewed between 13 and 39 days (mean = 22 days) after the consultation when their test was taken. Contact was attempted with a further 19 patients who either then declined the interview or were not contactable by telephone despite repeated attempts. Two key themes were developed from the analysis: ‘Presenting in primary care and deciding on a care pathway’, and ‘Communicating and managing test results’. Findings are illustrated using anonymised verbatim quotes.
Presenting in primary care and deciding a care pathway
Consulting primary care for an STI
Patients valued consulting primary care for STIs. Some female patients referred to stigma associated with being seen using sexual health services as motivation for preferring primary care practice.
“…it’s a bit of a stigma, because people know what that specific [GUM] clinic is… and it’s one of those things where, well, what if someone sees me that knows me? They might, you know, and make assumptions” (Patient 5)
Some patients who tested positive had consulted primary care previously regarding their symptoms before being offered an STI test. Patients thought that opportunities had been missed to diagnose and treat them earlier:
“I was hoping to have treatment. ‘Cos the first two doctors I’d seen before then, they just kept passing it off as thrush.” (Patient 7)
Discussing nurse led telephone management
Despite the online consent being completed, a minority of patients had no recollection of NLTM being discussed and or had not understood what it involved. Several patients mentioned that the consultation had been in the context of stressful life events, which may have affected their recollection:
“I can’t remember at all…I was distraught… at the time when I spoke to my doctor.” (Patient 8)
HCPs mentioned having excluded a patient because their first language was not English, because of patients’ learning difficulties and because the HCP wanted to see the patient for follow up regarding other issues. Another GP decided not to discuss the intervention with some patients she saw as being “ridiculously anxious already” (GP 15). The commonest reason intervention practice HCPs gave for not consenting patients related to time pressure/frustration with ICE system online study consent procedures, which also contributed to some patients being assigned to an incorrect study arm. If an HCP felt too busy to recruit, they chose the earliest possible exit option on the ICE system (e.g. ineligible or decline consent). The ICE system was subsequently simplified following feedback.
“Initially…. because it [ICE] was so clunky, and if you were in a rush, it was quicker to press, “No” (GP 7)
Most HCP did not find explaining the NLTM to patients negatively impacted on consultations. HCPs reported that the vast majority of their patients were happy with NLTM and did not raise any questions or concerns.
“I usually say, ‘The way positive results are going to be managed is that somebody, with your consent, will contact you from the screening service that already deals with the screening programme, so they’re well used to doing it.’ And most people say, ‘Oh yeah, that’s fine’.” (GP 5)
One GP did think explaining NLTM, along with the need to check the phone number, would be more time consuming “as opposed to, ‘Have your result, if it’s positive come back and see me and we’ll sort it out’” (GP 3). However, they thought that some of this time might be recouped in the longer term via NLTM managing results. Another GP was concerned that, if the STI test was part of a broader diagnostic process, discussing NLTM could put unwanted emphasis on the possibility of a STI:
“If someone has just come in with a vaginal discharge and they’ve got a regular partner, and you’re saying, ‘I’m going to do some swabs for infection that includes sexually transmitted infection but also includes non-sexually transmitted infection’, to then have to really focus on, you know, ‘A nurse is going to ring you if you’ve got chlamydia’, you’re sort of - it escalates the anxiety about what’s going on. And particularly patients with pelvic pain and stuff that often are very anxious anyway.“(GP 15)
Communicating and managing test results
Health care professional uncertainties about intervention procedures
Most HCP mentioned uncertainties regarding NLTM procedures, including when the NLTM would contact patients, and when, if at all, the HCP would be informed about what care had been provided, or be notified if the NLTM had not been able to contact the patient. A minority of HCP did not know that patients with negative results were informed by text, and one GP had told patients that they still needed to call the practice. HCPs acknowledged that if NLTM was usual care, rather than a new initiative, they would be likely to have be more confident that the patient was being appropriately managed.
“if something’s new you’re just not sure how failsafe it is, so I just told people, ‘You must phone us back anyway. But, you know, basically you should receive a phone call from, you know, the specialist hub.’” (GP 16)
HCP retained a strong sense of personal responsibility for the patients whose tests they had initiated:
“As the person taking the test, you kind of feel obligated, by the way we’re trained, to follow it up. So, I think that’s what I would do… I guess I might, after the first few positives, I might just become more confident and leave it.” (GP 4)
A minority of HCP reported that they had checked that a patient had received results and infections were being managed, and others said that they would have done this if a positive result had come back:
“Well initially maybe it was me who wasn’t aware of how things worked. I mean I think there was one positive result which - I wasn’t sure whether it was being acted upon or not. So, I kind of just did a prescription and, you know, asked the receptionist to find out if he has had a phone call. Because it was a positive result, I just wanted to act upon it… the receptionist got back to me and said that, ‘No, he has already had a [NLTM] phone call.’” (GP 1)
It was important to HCPs that there was a mechanism to ensure that they were kept fully informed in a timely manner regarding the care their patients were receiving:
“I didn’t want to just leave it, in case [NLTM] didn’t get hold of her. …I think it would be nice to have confirmation that.’” (Nurse 14)
Patients appreciated getting a text message regarding a negative result and found this preferable to a ‘no news is good news’ approach, or to having to try and contact their practice to obtain results.
“I thought it was good because you get it straight away then, isn’t it?...Trying to get through to a GP surgery is a bit of a nightmare nowadays… it’s good, just have it – peace of mind as well, everything was alright.” (Patient 1)
Patients in general considered having a telephone consultation regarding positive test results/treatment acceptable, and significantly more convenient and timely than a face-to-face appointment. Some patients said that they would feel more comfortable having a results conversation by telephone as “In person it’s quite embarrassing” (Patient 3). Patient 4 thought that dealing with a positive result would be easier if she was in her “own environment”, rather than having to “hold it all together” in front of the GP.
Appeal of a ‘specialist’ nurse led service
Being contacted by ‘specialist’ nurses was considered attractive by many patients, for a range of reasons. Some patients expected usual care to involve being contacted by primary care reception staff - when checking results or making a follow-up appointment. In one case this increased the patient’s concerns regarding confidentiality:
“...these receptionists live in the area. And I’m not saying they’ll go and blab things out, but I don’t want them to know my business. So, if it was dealt with by someone who was specialised in that and then you don’t even have to involve the doctor, that’s way better.” (Patient 8)
Another patient had concerns about the level of expertise needed to communicate results:
“I always have a bit of doubt when I ring my GP surgery to get results from tests, whether, because it’s the receptionist telling me, I don’t – I do have a bit of concern whether she’s misread them or not read them properly. Whereas if it was someone who specialised, you know, in that kind of thing and they’re ringing you, then you know, I think you just have a bit more confidence.” (Patient 5)
Some patients also mentioned the appeal of receiving results from someone who could immediately answer questions and arrange treatment. Patients expected specialist nurses to have more expertise than GPs, which was reassuring:
“If it was with a specialist it would probably make you feel better. So, the doctor, when I was speaking to her, she didn’t really know a lot. So sometimes, if they don’t know a lot and they’re not very certain themselves, it makes you uncertain. Whereas if you get a phone call from someone that knows what they’re talking about, it makes you a little bit more at ease.” (Patient 4)
Patients were also aware of GP workloads, and expected a specialist nurse to have more time to discuss results:
“I’d prefer to speak to someone whose specific role was to speak to people about this, rather than a GP who has got many other responsibilities and might not give you the right time to discuss it.” (Patient 11)
HCPs referred to the fact that the NLTM service was already in place and working well for younger patients via the NCSP and saw extending this to everyone as positive, being able to provide timelier follow-up, and better partner notification.
“But it’s quite nice to know that if it was positive then there’s another service going into the notification and making sure they get their treatment and stuff. Because …sometimes it’s quite hard to get hold of a patient and, you know, I’m only in here two days a week.” (GP 15)
Views on partner notification
HCPs expressed the view that partner notification in primary care could be “a bit haphazard” (GP 2), and that NLTM would be better placed to manage this.
“[GP’s name] who was very good…but he said actually, more often than not, he would refer [partner notification]. But it’s simply because of time management that he just didn’t have time to sort it all out, and we didn’t have anybody in admin or any nurse, you know, that would sort of – he could palm that off.” (Nurse 13)
While no patients objected to being asked for details of partners, views on the best way to manage partner notification varied. While some wished to notify partners themselves, others
who expressed a view regarding whether this discussion was with their GP or the NLTM were either neutral, or preferred NLTM:
Patient 8: I’d be quite happy, if I knew I’d got some infection or something I’d be quite happy to say, ‘Well it’s this person, that person or that person,’ you know.
Interviewer: And would you find it easier to be talking to a specialist nurse about that or to be talking to your GP?
Patient 8: Specialist nurse definitely, yeah.