Examination of Witnesses (Questions 1-19)
MS CATHY
HAMLYN, DR
VICKI KING,
MS RUTH
STANIER,MS
KAY ORTON
AND MS
ANDREA DUNCAN
WEDNESDAY 26 JUNE 2002
Chairman: Colleagues, can I welcome you
to this first meeting of the Committee's inquiry into Sexual Health,
and particularly welcome our witnesses; we are very grateful for
your co-operation with our inquiry. As this is the first meeting
of this inquiry, we normally do require any declarations of interest
that may be relevant to the inquiry.
Julia Drown: As we say in other inquiries,
there are bound to be some people working in this field who are
UNISON members.
Chairman: Okay; well I will declare the
fact I am a UNISON member and receive support from UNISON at general
election times.
Julia Drown: Or your constituency does;
likewise.
Andy Burnham: I declare likewise.
Sandra Gidley: Indirectly, I think I
ought to declare, I am a member of the Royal Pharmaceutical Society,
which may be regarded by some as an interest, maybe getting some
election expenses.
Chairman
1. Thank you very much. Could I ask each of
our witnesses to briefly introduce themselves to the Committee,
starting with you, Ms Orton?
(Ms Orton) Kay Orton. I work in the Sexual Health
and Substance Misuse team in the Department, and my interests
are around HIV, including HIV prevention, and health promotion.
(Dr King) I am Vicki King. I am a microbiologist and
I work in the Communicable Diseases branch of the Department of
Health. And I am Head of a unit which is entitled Blood and Healthcare
Associated Infections Unit, and that also covers hepatitis B and
C and some aspects of HIV.
(Ms Hamlyn) I am Cathy Hamlyn. I am Head of Sexual
Health and Substance Misuse in the Department of Health. I am
responsible for implementation of the Sexual Health and HIV Strategy,
and I am also responsible for implementation of the Teenage Pregnancy
Strategy.
(Ms Stanier) I am Ruth Stanier. I am Cathy Hamlyn's
Deputy.
(Ms Duncan) I am Andrea Duncan. I work with Cathy
and Ruth, and I work on reproductive health and STIs.
2. Thank you very much. What I wondered if we
could start with is a brief question on how the different elements
of relevance to sexual health within the Department knit together,
structurally, and how perhaps the different elements within Government
knit together in the development of a strategy on sexual health?
I do not know who would like to tackle that, as a starter?
(Ms Hamlyn) When the strategy was actually being developed,
there were separate branches within the Department of Health who
dealt with teenage pregnancy and who dealt with sexual health,
which included HIV, promotion, prevention and, indeed, HIV treatment
was dealt with by a separate branch, but that has now all come
together, it has all come together under me; but I also deal with
substance misuse, and obviously there is a link with drug-injecting,
drug users. That has now all come together in one entity under
me in the Department of Health, but we work very closely with
the Communicable Diseases branch, and Vicki has already explained
some of her responsibilities, in that respect. Now this was developed
very much as a Department of Health strategy, but clearly there
are a lot of linkages across Government. The Teenage Pregnancy
Strategy is a cross-Government strategy, and we already have a
cross-Government Interdepartmental Officials Group, as well as
linking into ministerially, through the ministerial groups on
children and young peoples services, and social exclusion, those
two ministerial committees. What we have done since the strategy
was initially developed, and through the consultation, is to build
upon our links, and we already have good bilateral links with
a number of other Government Departments, which we have done routinely
over quite a number of years, whether that is the Home Office,
whether that is DFID, whether it is the Department for Education
and Skills, and the Department for Education and Skills are very
keen, for example, for sex and relationships education as part
of the Teenage Pregnancy Programme. And it is our intention to
build upon the interdepartmental group that we have for teenage
pregnancy now, to build upon that in order to take forward the
cross-Government focus which this strategy is being developed
as, and, indeed, I hope that you would agree is reflected in our
Action Plan recently published. So we have a number of different
mechanisms for good working across Government, which we intend
to build upon.
3. Thank you. The problem, in relation to STIs
has been pretty apparent for some time, and obviously, as a Committee,
one of the reasons that we are looking at this area is because
of the concern over the rising extent of problems in this area.
Without getting into the political side of this, and I appreciate
that would be inappropriate to ask at this stage, we may ask Ministers,
why has it taken till 2001 to develop a national strategy; what
would you identify as the kind of key influences behind the development
of a strategy, from your own point of view within the Department?
(Ms Hamlyn) This is clearly a serious and significant
public health issue, and, yes, it is the first Government strategy
that has really tackled sexual health and HIV; and originally
those two were being developed separately, and they come together
in this one strategy. And it is in the context of the increasing
and rising trend in sexually-transmitted infections, that has
been very apparent over the last few years, and the increasing
prevalence in HIV. There is a lot of work done on HIV by the Department,
but we need to have a renewed effort, given that we are seeing
an increased prevalence of HIV, in particular, the new diagnoses
in 2001 increases over 2000 that we are seeing an increase in,
the greatest proportion now being through heterosexual transmission,
although the greatest proportion of those are being acquired abroad.
So it is very much in the context of those rising trends, and,
indeed, we need to have a renewed emphasis on HIV. There is also
the context of very apparent pressures on services, and, indeed,
a number of issues that have come up through the consultation,
through the development of the strategy, and, indeed, the subsequent
consultation on pressure of services, increases in waiting times,
whether that is talking about GUM or the problems around abortion.
I think it is in recognition of all of those issues, about the
importance, therefore, of having a strategy that really pulls
together and really starts to tackle these issues.
4. It just seems a bit strange that we have
had a National Health Service since 1948, and we have had significant
problems in this area over that period of time, which has impacted
in many ways on the Health Service, and I have mentioned to some
colleagues previously that, certainly, working in the mental health
sector, I came across people who had mental health problems arising
from a sexually-transmitted disease, and I am sure you are aware
of the nature of that problem. It just seems very surprising to
me that we have taken so long to actually sit down and develop
some coherent thinking at Government level on this issue. I am
not being critical of you, you were not around over all that 50-year
period. I just wonder what your thoughts are as to why we have
suddenly become aware, far more aware, than we have been previously,
when, presumably, years and years ago, we could have been developing
some of the ideas that you have come up with now, that would have
made a difference to a significant number of people?
(Ms Hamlyn) I cannot speak to the history, as you
quite rightly said, and I only joined the Department myself a
couple of years ago, so I could not speak on that history; some
of my colleagues may be able to comment further. But I would not
like you to go away thinking that there were not a lot of things
going on.
5. I appreciate that. We are talking about a
national strategy, of course?
(Ms Hamlyn) Yes; there was not an overall national
strategy which brought those issues together, but there was a
lot of work going on in terms of health promotion; the Health
Education Authority, as it was then, had been doing a lot of work
on sexual health, we had campaign work going on, we had both on
HIV in general and targeted health promotion had been going on.
So I would not like you to think that it was not—yes, this
is the first time there has been a strategy that brought all those
things together.
6. Do any of your other colleagues want to come
in on that general area: Dr King?
(Dr King) I could perhaps say something on that, a
little bit about the historical context. I think the whole area
of STIs, and HIV, of course, came much more into focus after the
first AIDS cases, they are described in the States and then in
this country, so we are talking about 1981/1982. So that clearly
brought it all into focus, and a number of certainly health promotion
initiatives came about then, that I think we are still reaping
the benefit of, if we actually compare the prevalence of HIV in
this country with the prevalence in other countries that perhaps
did not take those initiatives quite as early, in the mid 1980s.
Sandra Gidley
7. The Sexual Health Strategy, I just wondered
if it, in effect, was slightly misnamed, because it concentrates,
probably quite rightly, on HIV and STIs, but if you look at sexual
health in the wider sense then perhaps you should also be covering
in more depth areas like sexual dysfunction, whereas, in fact,
I think, if you read the strategy, it was one paragraph on the
subject, if that. Now when we get very exercised by the figures
on sexually-transmitted diseases, and I think they are shocking,
we do need something to be done about them, there a lot of people
out there, and the figures are not collected, who suffer from
problems with sexual dysfunction, yet they seem to ignore it,
because it is not a target that can easily be met. Why is there
scant attention paid to that area in the strategy?
(Ms Hamlyn) There is, within our Action Plan, a clear
commitment to develop standards, in respect of psycho-sexual services,
that include sexual dysfunction, and, more broadly, as I say,
there are other standards actually mentioned in there and overall
clinical practice guidance, so it is an area that we will be developing
further, with those standards being developed and widely disseminated
to the service.
Chairman
8. Can I mention, before I pass on to some of
my other colleagues who want to come in with questions, one of
the bits of evidence that we have received in this inquiry, from
the Medical Foundation for AIDS and Sexual Health says, and I
quote: "the nation's sexual health is deteriorating".
Is that an impression that you have, in your position, of the
overall picture?
(Ms Hamlyn) I do not think we can deny the increasing
prevalence in, as I was mentioning, sexually-transmitted infections
and HIV, I do not think we can deny the facts as they speak for
themselves, and we have seen, over the last five years, increases
in gonorrhoea, chlamydia, syphilis, of over 100 per cent, and
those increases are still going on. So I do not think we can at
all deny that we need to address those issues, and, indeed, that
is why we have a strategy to do so.
9. But you would not necessarily say it is deteriorating?
(Ms Hamlyn) It is not getting any better.
Chairman: Well, that is an interesting answer.
Andy Burnham
10. Just on that point, can I ask you a few
questions about young people, in particular, and ask you whether
the nation's deteriorating sexual health is linked to a change
in attitudes amongst younger people? From figures which the Committee
have been given, from the National Survey of Sexual Attitudes
and Lifestyle, it portrays fairly big increases in sexual activity,
including numbers of partners, and just generally people seem
to be more sexually active, and active at a younger age as well.
Is that a fair assessment of changing habits amongst young people?
(Ms Hamlyn) I think we do need to set this in proportion,
but the average age of first sex is not dissimilar to other countries.
Between the last ten years, in respect of the Natsal study, it
showed there was, in fact, a difference in the age of first sex
from 17 to 16, that is the difference; there are still only about
a third who have sex before 16.[1]
11. It says in the figures we have though, if
you do not mind me interrupting, quickly, that age at first intercourse
for women has fallen from 21 to 16?
(Ms Hamlyn) Yes; over a period, that is true. If you
went right back to earlier last century, in the 1920s, you would
probably have been talking about only 1 in 25, 1 in 20, who had
sex before the age of 16; that has changed over time, I think
we recognise that. There are a couple of other things in that,
that I think are significant as well, and again colleagues may
wish to comment further, that young people were acting, you could
say, more responsibly during that period, that, in fact, condom
use has increased, the figures quoted in the previous Natsal were
that only something like 50 per cent of under-16s and 66 per cent
of 16-19 year olds were using condoms at first sex, and that figures
has now improved to 80 per cent, so there is a greater awareness
of the need to act responsibly, if you are going to be sexually
active. But that has been, to some extent, counteracted by the
fact that, yes, Natsal was also saying, as you quite rightly say,
there are increases in the number of partners. So there are differences
there. A lot, obviously, of what we are doing in relation to under-18s
is being picked up as part of the Teenage Pregnancy Programme.
Clearly, one of our priorities now, in the context of the Sexual
Health Strategy, is to look at young adults, and that is really
where the biggest increase in sexually-transmitted infection rates
is, really from the age of 16 up to 34, so that is very much a
strong focus.
12. And could I just ask, is my assumption that,
over the course of the last century, there was an ever-increasing
trend towards more and earlier sexual activity by young people,
and that it is not cyclical but it is just becoming more and more
and more and more, as we move on? However, in terms of looking
at the history of society, going back centuries, does this move
in cycles, or is the evidence that we are becoming a more promiscuous
society?
(Ms Hamlyn) I think there are differences between
talking about age of first sex and talking about promiscuity,
I think there are differences between those two things. What I
was referring to was, in fact, yes, the age of first sex has undoubtedly
come down, it has come down in other countries as well, and it
had come down over a number of years, over that period. I think
that is rather different from talking about promiscuity.
13. But do you think there will be a backlash,
at any point, that the moral climate changes, or do you think
that—
(Ms Hamlyn) I am not sure I am in a position to predict
what will happen in that respect. What we are trying to approach
is to give people the information, because certainly for young
people it is about giving them the information they need to make
the right choices for them; you want to ensure that young people
do not feel pressurised to have sex early, that they are given
the skills that they can indeed say "no" when they do
not feel it is right for them. Indeed, there is a lot of misinformation,
there is an assumption amongst the young peer group that everybody
else is doing it, when in fact that is clearly not the case.
14. Are you confident, in the Department, that
you are doing enough to track and to tap into what young people
are thinking and saying about sex amongst themselves, and actually
what they are doing at weekends? Do you have the mechanisms within
the Department to monitor those trends?
(Ms Hamlyn) We have quite a number of different mechanisms
around young people themselves, in terms of them telling us about
what some of the issues are. And within the Teenage Pregnancy
Programme we commissioned Barnardo's to bring together the best
possible evidence about how you involve young people; we put that
together into a guide, and backed that up with training across
the country, in a number of seminar programmes. We also have,
through the support of the National Children's Bureau, a Young
People's Forum, and the National Children's Bureau, also on our
behalf, carry out targeted consultations with particular, different
groups of young people, and they could be young people in care,
young offenders, and so on. So we have quite a lot going on within
the Teenage Pregnancy Programme. Within the context of the development
of the Sexual Health Strategy, in the early days of developing
the strategy, there were a number of events specifically with
young people, and then, subsequently, we supported work in doing
a targeted consultation on the strategy document itself, with
young people. Also, within the context of the development of the
campaign within the Teenage Pregnancy Programme, we did some thorough
research, drawing together the best possible evidence about what
works with young people, and on public health campaigns in general,
both here and abroad, that are specifically in respect of sexual
health, and drew on not just looking at what works, in terms of
increasing knowledge for changing behaviour, but we also looked
at lifestyle issues, as part of that. And, similarly, we commissioned
and received the same type of research for the younger adults,
up to age 30. And with our teenage pregnancy advertising campaign,
in fact, we test all our adverts with young people before they
go, so we get a real feedback. And as part of the national evaluation
of the Teenage Pregnancy Programme, we have a tracking survey
with young people, we have it with parents too, but we have it
with young people, where we have 700 young people three times
a year, we are testing their knowledge, their attitudes, over
time, we will be able to track where we can see changes in attitudes,
behaviour.
15. On teenage pregnancies, why do you think
it is that Britain traditionally has had an extremely high rate,
indeed, the highest in Europe, what factors would you identify,
say, three or four, as to why we have always led the way?
(Ms Hamlyn) The original Social Exclusion Unit report
really talked about three main reasons, and they were around low
expectations in life, that if you have ambition, that you have
opportunity, then you are less likely to—
16. I suspect that is the main one, would you
say that?
(Ms Hamlyn) I think that is the main one, too, and
certainly, when we look at the correlation between high rates
of teenage pregnancy and the areas concerned, there is a correlation
with deprivation, there is a correlation with [2]social
class and poverty.
17. Would you expect the more young people who
go into higher education that the teenage pregnancy rate would
fall?
(Ms Hamlyn) Yes, I think that is very much part of
our strategy, along with looking at sex education and looking
at improving services, it is also about improving opportunities,
getting young people back into education, training and employment.
There were two other reasons within the Social Exclusion report
that were identified, which were around ignorance about knowledge
about sex and relationships and contraception, not just about
types of contraception but how to use contraception properly and
where to get it. And a third area really was the mixed messages
of society, that, on the one hand, we find it quite difficult
to talk about sex and parents find it quite difficult to talk
about it to children; on the other hand,—
18. The British are more buttoned-up about this
kind of thing?
(Ms Hamlyn) I think, indeed, but a lot to do with
our culture, but, on the other hand, young people do get bombarded
with quite a lot of sexually-explicit images through the media,
so there is quite a conflict in our society. They are the main
reasons.
19. There was a 2.4 per cent decrease in the
number of teenage pregnancies in 1999-2000?
(Ms Hamlyn) It has been over 6 per cent, from 1998
to 2000.
1 Note by witness: Data from NATSAL 2000, published
in the Lancet on 1 December 2001, showed that the proportion
of those aged 16-19 years at interview reporting first heterosexual
intercourse at younger than 16 years was 30 per cent for men and
26 per cent for women. Back
2
Note by witness: [lower social class]. Back
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