Examination of Witnesses (Questions 40-59)|
WEDNESDAY 26 JUNE 2002
40. Can I be provocative about prevention, because
I think we are losing the battle. When STIs and HIV came into
prominence a few years ago, there was tremendous publicity about
the risks and the fears, and because the widespread epidemic has
not, thank goodness, occurred in this country, people are becoming
complacent. I was very sad to hear you say that heterosexual infections
now are so often acquired abroad; people know that if you go to
the continent of Africa the incidence is tremendous. What are
we doing about alerting people, when they go abroad, that they
are putting themselves at tremendous risk, if they do have sex,
of any sort, really?
(Dr King) Can I just say something about the epidemiology
there, I am not sure if you have actually got it quite right,
or maybe I have misunderstood what you said; but the make-up of
the epidemic in this country, in terms of the sort of percent
through the various risk groups, is round about 30 per cent in
gay and bisexual men, and this is newly-diagnosed HIV infections,
and over 50 per cent in heterosexuals, and a small percentage
in injecting drug users, and a small percentage in mother to baby.
But the point about the heterosexual group is that more than 80
per cent of those infections are infections that, in fact, were
transmitted in high-prevalence countries, yes, and predominantly
sub-Saharan African countries, but these are also predominantly
in newly-arrived people from those countries, so they are from
those countries as migrant populations.
41. So it is not vast numbers of tourists going
out from here?
(Dr King) No; exactly.
42. Well, thank goodness for that.
(Dr King) Because I think that was what I had assumed,
from what you had said. But we do have health promotion materials,
which are very widely available, to alert travellers, who are
going to countries of high prevalence of HIV, about the risks
of unprotected sex, about the risks of sharing injecting equipment,
about the risks of medical or dental interventions, in countries
where the infection control procedures are not as good as ours,
about the risks of blood transfusion in those countries where
they do not screen for blood-borne viruses. I think Kay can probably
tell you a little bit more about advice for travellers.
(Ms Orton) And, also, the Department funds two leaflets,
one on Health Advice for Travellers and one on Travel Safety,
which is specifically around the risks of HIV abroad.
43. And you are satisfied that these are being
taken note of?
(Ms Orton) We like to think so, yes.
44. How do people access these? Only people
who are fairly, probably, circumspect would pick these up; is
there any will to, I do not know, dish them out with your air
(Ms Orton) The leaflets are available from some travel
agents, but it is up to the individual travel agent.
45. But people do not always want to be seen
to be picking up one of these leaflets, when their neighbours
might be in the travel agent at the same time?
(Ms Orton) The Travel Safety that I am talking about,
it is designed in such a way that it does not have "Avoid
AIDS when you go overseas", it is designed in such a way
to avoid that particular issue; it is also available from GP surgeries
46. Coming back home, onto the matter really
of the distribution of GUM clinics, and the actions of those.
Really, we have been terribly disappointed to learn of the delays
that patients are going to have in accessing the GUM clinics.
In our evidence, I think it is St. George's Hospital, the Courtyard
Clinic, "Our walk-in clinics are currently working to full
capacity; indeed, our clinics have been unable to operate an open-access
service for 18 months." And that where you have an appointments
system, people are having to wait days, seven to ten days, for
an appointment. And the sort of people, probably, who are wanting
to access these clinics, they will sort of forget about it and
not care about it. What measures have you got to improve access,
what plans, can you aim for a maximum waiting time?
(Ms Hamlyn) It is a significant issue. I think I referred
to the increase in waiting times, that the average waiting time
for a first appointment has lengthened, from five to six days
in 2000, to 12 to 14 days; and we know that there is evidence
in the country where there will be situations that are worse than
that. Now in our Implementation Action Plan, within the monies
that we have available this year, we have referred to £6
million for abortion and GUM, the vast majority of that will be
for GU clinics, and we are in discussion with the GU speciality
about the best way that that can be distributed, targeting the
areas where there is the most need, clearly, where there are issues
of high case-load, where there is high prevalence, where they
are single-handed GU consultants, and where there also has been
a record of delivery, which I think is significant for us. I think,
if we distribute money to areas which historically have not invested
properly in GU services, then we are rewarding really the wrong
decisions, although there could be ways in which we could look
at matched funding situations. We are also looking at, and it
is referred to in the Action Plan, proposing the review of the
skill mix within GUM, looking at working practices, skill mix
issues, for example, the different use of, whether we are talking
about doctors, nurses, HIV and the health advisers actually within
GUM. And we will be looking at our overall workforce planning
assumptions, in order to be able to improve services, and particularly
a robust model is again referred to in the Implementation Plan,
about really looking at the impact of waiting times on sexual
health outcomes, really modelling that, so we have a very clear
answer to that. Clearly, investment, and, as I say, a kind of
review of how things are going are key; we can only do so much,
in terms of pump-priming monies. I think a key is also going to
be the mainstream resources that go, on a day-to-day basis, from
the NHS budget into GUM, and, clearly, in any local area where
they have those kinds of situations, that is a local decision
that really needs to be made in terms of proper investment going
in. As I say, we will have some pump-priming money, but PCTs will
need to secure adequate investment from their mainstream resources
to make the kinds of improvements we are talking about. I have
had discussions with the GU speciality, about a concern about
really gearing up GUM, before we put additional pressure in terms
of uptake, and that is an issue that we have been seriously looking
at. It is important that what we can do in terms of pump-priming
investment goes out there as soon as possible, so that services
can start to gear up to improved services, improved waiting times.
We do have a waiting time indicator that we are intending to develop,
and that is part of the Action Plan specifically on the question
of waiting times. And one of the issues that the GU representatives
of the speciality have raised with us is about worries about,
if we do a campaign, whether that will increase pressure, and
that is something that we are seriously looking at. And, whereas
we are reluctant to delay appreciably having a campaign, for all
the reasons we have already been talking about, the importance
of getting over messages about awareness around sexually-transmitted
infections, I think we do recognise the need for gearing up services
to be able to cope, and we are looking at that in the context
of how any advertising campaign will be rolled out, the timing
of some of that, in the context of how we can gear up and ensure
that GUM are properly geared up, in terms of improving their current
position, actually, on those issues.
47. Can I clarify, is this £6 million recurring,
or just a one-off?
(Ms Hamlyn) I am talking about pump-priming money
for this year. As we have indicated in our Action Plan, in terms
of funding for subsequent years, that is subject to overall decisions
that need to be made in the outcome of the Spending Review, at
the present time, so we cannot confirm what will happen beyond
this year. Clearly, there is the broader issue, that the NHS is
getting an increase in overall resources, in terms of mainstream
resources, which is there to improve all services, that includes
improving where there is a dire need to improve GUM; and, again,
that is down to the local decisions to be made.
48. But really it is going to be up to PCTs
to insist on getting an extra GU consultant in their area?
(Ms Hamlyn) I think that the whole emphasis of our
approach to the Health Service in general is about local decision-making,
local priorities, so a key issue is about PCTs looking at those
kinds of problems in their area and then doing something about
49. But there is not a lump of extra money coming
in automatically to get extra consultants in GUM?
(Ms Hamlyn) There is a lump of money coming in, as
I say, this year; as I said, whether there will be any further
money available for GUM has to be subject to exactly how much
that might be, coming from the centre, as a specific allocation,
will have to be subject to decisions about the overall outcome
of the Spending Review settlement.
Chairman: Could I just ask, on the pressure
on GUM clinics, has any thought been given to how we might make
better use of primary care facilities? I appreciate, obviously,
that many people would not wish to, because of the stigma, etc.,
go to their own GP, but, have I stolen your question? I am sorry,
I will get you upset with me now.
Dr Naysmith: No, no.
50. I meant stigma, actually to their own GP
for this particular issue. It just struck me that there are ways
and means possibly of making better use of the opportunities we
have now with PCTs; is that impractical, the reasons why specifically
people have to see a consultant? I would have thought, from my
limited knowledge of this area, that it may be we could look at
that issue; is it something that you have thought of?
(Ms Hamlyn) I think we are looking at a number of
different models, we are looking in a strategy within the framework
for the model services, we talk about a Level One, Level Two,
Level Three service. Level One refers to what would be available
in any local area, whether that is through GUM facilities or through
general practice, that we want to see HIV and STI testing, for
example, actually provided at that kind of local level, but more
specialist services provided, and we refer to Level Two and Level
Three. We are not talking about doing everything in primary care,
but primary care, undoubtedly, and GP practice, have a role to
play in this. And, as I said, I think it is something that we
need to develop over time, general practice may feel already that
they have got a lot of other priorities and pressures on them
too; so I think it is something that we will be working on with
the Royal of College of GPs, and will be developing over time.
We can look at different settings; we also have in the strategy
the idea of piloting One Stop Shops, where you go for your contraception
and you get the potential to be tested, STI-tested, and so on,
so there are different models that we can look at, that it is
not just one size fits all, and, of course, different models may
be appropriate for different communities.
51. It is an area I wanted to explore, this
question of primary care and the stigma that does apply, in some
cases, and the Chairman has already referred to that. But is there
a willingness on behalf of general practitioners, in general,
to get engaged in this sort of medicine, do they want to expand
it, really, was what I wanted to know?
(Ms Hamlyn) I think it varies. I think there will
be the enthusiasts, who
52. This is why you want to talk to the College?
(Ms Hamlyn) The College, and indeed some of the people
within their specific task force, are looking at some of these
issues within the College. There will be enthusiasts who really
want to ensure that this actually is developed further within
general practice; and during consultation we heard of some parts
of the country where general practice really wanted to develop
not just Level One but Level Two, for the majority of practices
in Essex, this was one example where the majority of practices
were suggesting they wanted to do Level Two. So it will vary across
the country, and I think we do recognise it is a long-term plan
we need here, to look at, discuss with the profession, PCTs need
to explore it locally. I think the importance is though, at any
local level, about giving a choice of services; and this is, indeed,
what people were saying to us, through the consultation, that
they do not want to feel that going to general practice is a serious
thing, any more than they want to feel that GUM, and people feel
differently about the stigma attached to both of those; some will
go to general practice and feel that is the best for them, some
will not want to go to GUM, and vice versa. I think it does vary,
and we want to ensure that there is that choice, so that is available
53. It raises some interesting questions though,
in general, because we are moving to a system of diagnostic and
treatment centres, at least in theory, in some parts of the country,
which will involve consultants coming out from regional centres
or district hospitals and operating, operating in the sense of
working, much more in the community. And GUM clinics tend to be
located in, in my experience, well, in Bristol, the one that I
know best, it is in a prefab at the back of the BRI, and maybe
that is partly to avoid the kind of stigma, that gives them a
chance to move these things out much more into the clinic, using
the move towards diagnostic and treatment centres?
(Ms Hamlyn) I think we can take that and look at that
as an opportunity. I have said that we want to test the kind of
One Stop Shop model. There are examples round the country where
you have got a family planning clinic that are looking certainly
to chlamydia screening, and are looking to see what else they
could do on STI testing and screening. Size constraints are about
whether you have got laboratories on easy access, about some of
the models, but I think these are all things that we can explore
and look to see how we can improve access over time.
54. And how would the resources be worked out
(Ms Hamlyn) As I said, we have a commitment, with
the strategy, for £47½ million for the strategy, but
that can only be pump-priming money; the main source of money
for developing the service in this way will have to come from
the NHS budget, for which, of course, they have had a higher settlement
55. May I just come back, because our advisers
have picked up a point, very astutely. If we take a large city,
like this one, obviously, large numbers of the attendees coming
to GUM clinics come from outside the area, so they are not actually
under the PCT that is responsible for that area; so the new posts
have got to be based on local needs, because these patients may
not be of that PCT. How can you take that into account?
(Ms Hamlyn) The arrangements that previously applied,
and which we are encouraging to continue, are where PCTs work
in collaboration, and this is particularly important for London,
there has been a London commissioning group, specifically looking
at HIV issues, there has been one in the North West as well, and
it is where they work in concert together. And, indeed, in some
cases, where you may get one PCT acting on behalf of a number
of other PCTs, to look at the issue and really to combine available
resources to develop local services, it is within their commissioning
role that I am particularly talking about, although there are
also examples round the country where one PCT has acted on behalf
of the others in respect of provision of sexual health services
more generally as well.
56. That is actually happening in my own county,
where one PCT has taken on the responsibility for sexual health.
Now will the established NSFs, in things like diabetes and heart
disease, take money away from sexual health?
(Ms Hamlyn) I would say that there is an opportunity
through those, and perhaps Ruth could say a bit about those particular
National Service Frameworks.
(Ms Stanier) While there is not a specific NSF for
this particular area that we are talking about today, we are trying
to make sure that we get appropriate cross-references into National
Service Frameworks that are being developed. For example, diabetes,
the Diabetes NSF does include references to sexual health, and
we are similarly working to make sure that the Children's NSF
and the forthcoming Long-Term Conditions NSF do the same. In terms
of whether the NSFs will take funding away from the Sexual Health
Strategy, I think it is more the context that Cathy has already
outlined, that there are significant additional resources going
into the NHS, both to implement the NSFs but also to improve quality
right across the board.
57. First of all, I want to go back to the issue
about resources, clearly, all sorts of discussions are taking
place, in terms of the Comprehensive Spending Review, but, given
the quite alarming increases in infections and the untapped and
undealt with problems that are clearly out there, the increases
one might expect to see within departments even start dwarfing
the considerable amount of money that has already been identified
for the NHS. Do you have in your mind, can you tell the Committee,
the sort of increase in resources you think that departments would
need, over the intermediate term, looking, say, five years ahead?
(Ms Stanier) Are you talking specifically about GUM
departments, was that your question?
(Ms Stanier) We have not done any specific projections
that we have published ourselves. We are in touch with the speciality,
and they have provided some projections.
59. What do they think is needed?
(Ms Hamlyn) The projections that they have shown us
are that, in order to bring the current waiting times down to
deal with the immediate shortfall would require in a full year
£7½ million. I did say earlier that the majority of
the £6 million was going this year, and we will be issuing
really just for half a year, so it ought to make an appreciable
difference this year actually in terms of addressing some of the
waiting time. I mentioned earlier though the issue that they have
been worried about the impact of any campaign; they have done
some projections, in their opinion, about what impact a campaign
will have. I have to say that we take a slightly different view
about what the impact of a campaign might be, and it is probably
too early to say, but some of what they were drawing on was some
experience in terms of a campaign in Wales, where the information
we have had is that that has not brought about large increases
in the worried well, if you like, going to clinics. And the impact
of where we have had campaigns already, we have had some campaigning
going on already, but that again has not resulted in large increases
of people, again, the worried well, turning up to clinics. So
clearly this is something that we will need to keep close attention
to, in terms of the impact of the campaign; the campaign is not
primarily about directing people to services, it will raise awareness,
but it is about promoting condom use. But, yes, I accept that
there will be some people who will think, well, maybe they ought
to get tested. I think the question is whether that means that
they are rushed to go to do so, I think, is still a question-mark
that we clearly need to keep under review. I think that was why
I referred earlier to, as a result of our discussions with the
GU speciality, I think we are recognising that we need to make
certain that the speciality GUM clinics can cope, if there was
an increase in workload, and where we will time the roll-out of
any campaign accordingly. And we are talking about, potentially,
although we were talking about launching, announcing the campaign
in the autumn, the potential roll-out would be after Christmas,
and we will pace that accordingly, to allow the additional investment
that have I talked about to really take impact.