Examination of Witnesses (Questions 80-99)
MS CATHY
HAMLYN, DR
VICKI KING,
MS RUTH
STANIER,MS
KAY ORTON
AND MS
ANDREA DUNCAN
WEDNESDAY 26 JUNE 2002
80. Would you accept that the fact that we frequently
fail to address male health as a wider issue has a bearing on
the problems that you are addressing here; and do you have any
thoughts within your strategy on how we might be much more vigorous
about engaging with men? And if it is possible to test on the
basis of a urine sample, how we might sort of simplify, rather
than kind of having, I can recall, in my youth, hearing all sorts
of lurid tales about what happened if you got it, and the kind
of tests involved, that actually some of these tests are quite
simple, and it may be helpful for people to actually have these
in a routine way. Is that an area that you have given any thought
to?
(Ms Hamlyn) It was very well highlighted during the
consultation, the issue of men, particularly men and chlamydia,
and the need to look at different ways that men can actually access
support and services. We want to learn from other places, such
as in Scotland, they have been looking at postal systems for testing,
and so there are some other examples where we want to explore
that further. And, yes, I totally agree that there is a broader
issue about men's health. And there is some developing work to
really look at some of the broader issues around men's health,
and within which sexual health clearly needs to play a part.
Dr Naysmith
81. We have talked quite a lot about resources
already, but I did want to look at HIV, because of the changes
that have taken place, that it is now firmly back in the mainstream,
after having been specially funded for a while. Is it quite clear
that the responsibilities are, in terms of funding, between Primary
Care Trusts, Strategic Health Authorities and specialist commissioners,
is it clear and transparent who should be funding what? It is
HIV I am talking about, because of the way it has been changed,
in terms of its treatment, over the last few years?
(Ms Hamlyn) The key issue now is that PCTs have now
received, within their overall allocations, an element that is
associated, what previously would have been separate, in terms
of ring-fenced allocation for HIV treatment and prevention; so
PCTs have the key responsibility, in terms of commissioning. But
some of the arrangements, there is a transitional period where
there is an arrangement for joint commissioning of treatment,
particularly in the context of some of the points that were raised
earlier, where you are talking about treatment providers who provide
a service to a wide range of areas, it is the importance of those
commissioners coming together. So the intention is that there
will continue to be some of those collaborative arrangements;
so we are in a transitional period, where some of that expertise
will develop through Strategic Health Authorities, as now, previously
health authorities, playing some part in working with PCTs in
that transition, and, clearly, where we are also encouraging the
continuation of those joint commissioning arrangements. But PCTs
very clearly have the responsibility in terms of looking at their
local populations, as I mentioned earlier, their needs, in terms
of HIV prevention and sexual health contraceptive services, it
is very clearly with them. I think the issues I was talking about
were broadly around the way that treatment needs would be commissioned,
because of the issue that it is a specialist service.
82. Really what I am getting at is, there has
been some suggestion that some monies have been lost in the sort
of transfer in; are you happy to say that it is quite clear now
who should be commissioning what, which services, treatment and
preventative?
(Ms Hamlyn) I think it is quite clear, but it is an
issue that a lot of concern was raised on this issue during the
consultation period, and people were worried about what impact
it might have, that it would no longer be ring-fenced, and what
impact it might have particularly on the voluntary sector. In
our Implementation Action Plan, we have said very firmly that
we will be monitoring investment through the performance management
mechanisms that we have, through the Service and Financial Framework
that we have, to look at investment in HIV.
83. So what will the monitoring look like, how
are you going to do that?
(Ms Hamlyn) Through this Service and Financial Framework,
individual PCTs will be required to say what their investment
plans are and what they have spent; we also have the mechanism,
through the AIDS Control Act, where they are required to report,
and we will be reviewing the AIDS Control Act data requirements,
as part of the Action Plan. And we have, in fact, surveyed recently
and followed up on a sample to look at plans on investment, and
the majority, certainly from that survey that we have done, to
date, and we will have fuller information in August, suggests
that investment levels have been maintained, the majority, if
not increased, in some cases.
84. Is this, in effect, ring-fenced money then?
(Ms Hamlyn) It is not ring-fenced any more, no; that
was the major change that happened.
85. So it will depend on your monitoring deciding
whether or not the same amount of money is being spent?
(Ms Hamlyn) The decisions are dependent on the local
area; but we will be monitoring the impact, that was what I was
referring to, the monitoring mechanisms. Strategic Health Authorities
will take up the issues with individual PCTs, and ultimately the
Department can step in, if there really is an issue. I was just
going to mention the voluntary sector, because that was a particular
worry that was raised with us; and, again, we will be, through
the voluntary national organisations that we work with, asking
for their feedback on where perhaps that is impacting in a negative
way, if that is what happens, on particular voluntary sector organisations.
So we are setting up a number of different mechanisms to monitor
the impact of the decision on mainstreaming.
Sandra Gidley
86. Can I just clarify something, which I am
not quite sure of the situation. Currently, presumably, areas
like London and Brighton receive large amounts of money; will
that continue in the future? Because there are some parts of the
country where the prevalence is extremely low, and other parts
of the country where the prevalence of HIV is extremely high,
and, very often, those areas need more spent on public awareness
campaigns, targeted or otherwise, as well as the treatment; so
it seems unfair if everything is going to go into the pot, and
those areas with a high incidence do not receive some sort of
extra funding. So how will that be monitored?
(Ms Stanier) The arrangements that were made for mainstreaming
meant that, for this year's allocations, an amount of money for
each area, dependent on their HIV prevalence, was put into the
overall mainstream pot, and it will continue to be the case into
the future, that there will be, if you like, a hidden line within
the mainstream allocations, so those allocations will continue
to reflect HIV prevalence in particular areas.
87. But the spend will then be monitored to
see, how is that audited, in effect?
(Ms Stanier) As Cathy has explained, we will be monitoring
spend. I think, increasingly, looking into the future, we are
going to be looking more at how the rates are moving, and comparing
that against the particular interventions that local areas are
making.
88. Right; and if patients travel outside their
PCT, which can be some distance, because there are areas where
there is good treatment, but people may move from an area where
there is a low prevalence to an area where there is a high prevalence
to obtain specialist treatment, how do the PCTs providing that
patient's care get their money back? It sounds as though potentially
it could be quite bureaucratic?
(Ms Stanier) There has been an arrangement in place
between health authorities for such recharging to take place;
and we are developing the Commissioning Toolkit, that we refer
to in the Action Plan, and we are going to be providing further
guidance within that Toolkit on how these recharging arrangements
need to continue.
89. So you cannot really say at the moment,
is that right; all these toolkits and guidelines are all very
well, but it does not exactly help us to gain a clear picture
of what is going on?
(Ms Stanier) It is very complex, and members of our
team are currently talking with the profession to make sure that
we get the guidance that we do give right; though we do not have
a definitive answer.
90. So the fact that people need to, because
people do not want to be in a position where they are denied funding,
because this falls down. I think actually it is quite important,
if we are providing the service?
(Ms Stanier) It is very important, and it will be
sorted out during the current financial year.
91. Right; so you have to wait and see?
(Ms Stanier) I think that is what I have explained,
yes.
John Austin
92. Is there a danger that we have got a sort
of deserving and undeserving poor sort of scenario, that the Terrence
Higgins Trust has sort of made a comment that there may be a deprioritisation
of stigmatised groups, such as gay men, in favour of, say, young
people, and that the whole resource allocation may be skewed by
local commissioning? Do you think your monitoring is going to
be adequate to pick that up, and do you think that the fears of
the Terrence Higgins Trust are misplaced?
(Ms Hamlyn) I think this comes back to the way that
we actually look to the requirements through the AIDS Control
Act, and we can ask for information down to particular groups.
But I think that what I would say is that we have a full commitment,
in terms of our national resources, we already put, and Kay can
comment further, a significant amount of money through the Terrence
Higgins Trust for national programmes, through the CHAPS, the
Community HIV Strategy, for national initiatives around sexual
health promotion with gay men. So there is a commitment at national
level to continue with that. Do you want to comment further on
that?
(Ms Orton) Yes. For a number of years, we commissioned
the Terrence Higgins Trust for the CHAPS Initiative and plan to
continue; we are currently funding £1.1 million, and that
is a national initiative which we want to continue. We also fund
the voluntary sector, through something called the Section 64
support scheme, and we fund over £1 million on HIV/AIDS and
sexual health.
93. That is at sort of global and national levels;
and, in terms of local commissioning practices, do you think your
monitoring processes will be sufficient?
(Ms Hamlyn) I think it does come back to the other
guidance that we give, that Ruth was referring to earlier, that
the kind of priority groups, which were set out in the strategy,
will continue to be gay men, yes, young people is clearly another
one; in fact, we had a huge number of targeted groups that people
thought we ought to be addressing. But we will be addressing some
of those through the Commissioning Toolkit, through the guidance
we give to PCTs, in terms of commissioning practice, but at the
end of the day it will be PCTs to look to the local priorities
in their area, and I do not think you can get away from that issue,
that we are talking about local decision-making here, based on
local population needs.
Dr Taylor
94. I think we have had a lot on resources and
manpower. Specifically to Ms Orton, are there are any specific
promotion campaigns that you are about to launch?
(Ms Orton) The main one is the campaign that we mentioned
in the strategy, the Information Campaign for Young Adults, and
we are currently working with the design agency on developing
that, and that has been informed by a review of the research on
what sorts of messages and campaigns work best for this target
group. So that we are planning to launch that, and, as Cathy mentioned,
in the autumn, but the launch may well be phased to take account
of pressures that we have already discussed on GUM.
95. So we can look forward to that sometime
in the autumn?
(Ms Orton) Yes.
96. Is there an official strategy about HIV
testing, who should be tested, when they should be tested, right
at the beginning?
(Dr King) Yes, the strategy has a goal about HIV testing,
and this really is one of the issues that came up during the development
of the strategy, and that is, in this country, we have, the current
prevalence, I think, is 33,500 HIV-infected people; now approximately
a third of those are unaware of their infection, and so one of
the aims of the strategy is to decrease that undiagnosed pool,
so that people can be aware of their infection and receive advice
about preventing onward transmission, but importantly receive
advice about their own treatment and care. So that is a goal,
and in order to achieve that goal we have set a standard that
all people coming to a GUM clinic for an STI screen should be
offered an HIV test. This was informed by an expert group that
was set up, that included GUM physicians, and their observations,
and the evidence that some people were leaving GUM clinics with
HIV infection and still unaware of their infection, so it was
not being picked up because they were not actively being offered
an HIV test. And, in order to track how we are doing against this
goal, we have set a number of aims, in terms of uptake of the
test, and decreasing the numbers of undiagnosed infections, in
that group. But we have to bear in mind always that this is an
offer of a test, and it is not a mandatory test, and people have
the right to refuse that test.
97. Have you any idea of the sort of uptake?
(Dr King) The GUM physicians that were helping us
in formulating this, they had some evidence from their own clinics,
and they felt that 30 per cent uptake at that time was the sort
of uptake that they were getting, so we were putting it at 40
and now 60.[5]
Dr Naysmith
98. This is slightly unrelated to what has been
said, but since I have Dr King here I would like to ask the question.
I met an asylum-seeker this morning, a lady, who had a pregnancy
while in this country, and she was HIV positive, and she had tremendous
trouble accessing milk, either tokens or milk substitute, because,
of course, she did not want to feed her new-born child. Is there
any kind of programme to assist, because she was in emergency
accommodation when all this happened, and was unable to access
benefits properly; and this obviously happens occasionally, more
than occasionally?
(Dr King) Yes; as you are probably aware, it is the
Department's guidance that, in fact, HIV-infected pregnant women,
should be advised that one of the interventions, to prevent transmission
to their children, is the advice that they do not breast-feed;
and in this country, where there is access to formula milk and
to clean preparations, that advice stands and it is supported
by WHO and UNAIDS advice. There is an issue that we know about,
which is the one that you have outlined, and that is asylum-seekers
and the cost of formula milk; and we are in discussion with the
Home Office, and I believe there is a judicial review at the moment
currently looking at the provision of welfare foods, because formula
milk would come under that, and the regulations about welfare
foods and asylum regulations as well.
99. It would, of course, be one of the most
cost-efficient measures you can do, is to prevent the child from
becoming HIV-infected, just by providing some milk substitute?
(Dr King) Yes. I am aware that there are some local
trusts, and also most[6]
of our health authorities, that in fact did set up schemes, and
one not very far from here, in Lambeth, Southwark and Lewisham,
providing the sterilising equipment and the formula milk to their
HIV-infected—
5 Note by witness: The aim of the Implementation
action plan is to reduce the prevalence of undiagnosed HIV and
STIs-in particular, by setting a national standard that all GUM
services should offer an HIV test to clinic attendees on their
first screening for STIs, and working towards shorter waiting
times for urgent appointments in GUM services. Back
6
Note by witness: In retrospect, we are only aware of a
limited number of schemes. Back
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