Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 40-59)



Dr Taylor

  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.

Sandra Gidley

  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 tickets?
  (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 as well.

Dr Taylor

  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 them.

  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.

Dr Naysmith

  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 to people.

  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 there?
  (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 of money.

Dr Taylor

  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.

Julia Drown

  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?

  58. Yes.
  (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.

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