Examination of Witnesses (Questions 100-119)
MS CATHY
HAMLYN, DR
VICKI KING,
MS RUTH
STANIER,MS
KAY ORTON
AND MS
ANDREA DUNCAN
WEDNESDAY 26 JUNE 2002
100. So this is something that is on the Department's
agenda and is being addressed, is it?
(Dr King) It is on the agenda, yes, and we are looking
to find a way round it, it is quite complex but we are in discussion
with the Home Office as well about it.
Mr Burns
101. I thought if I could just go back to the
whole question of awareness, which I know two of my colleagues
have raised with you, fairly briefly. If one looks at your memorandum,
that we got sent in advance, it was interesting to see in one
part of one of your documents, saying that there were substantial
decreases in the incidence of STIs throughout the 1980s, but in
the last decade there has been a dramatic rise in diagnosis. One
also sees, in another of your memoranda, saying, "In 1999
most people questioned in a national study did not know what chlamydia
was." It also said that two surveys done by the National
Survey of Sexual Attitudes and Lifestyles in 1990 and 2000, show
that, in the second one, "there had been an increase in behaviours
associated with increased risk of HIV and STI transmission, including
increases in numbers of partners," and, "in particular,
there were considerably higher rates of new partner acquisition
Among those younger than 25 years and this is reflected in the
substantially higher incidence of STIs in this age group."
As you will be aware, there was, which I think was for the first
time ever, a very high profile awareness campaign through television,
through cinema, in the mid 1980s, which I think one of you said
earlier in this session did have an impact which helped make sure
that we were not, as a nation, on the back foot for the next decade
or so. We have not had that sort of high profile awareness campaign,
I think, to the best of my knowledge, for the last ten years,
and yet the evidence you are providing us with suggests that,
after, presumably, an impact of that awareness campaign, people
got lulled into complacency, a false sense of security, or whatever,
and, of course, a new generation has grown up that will be totally
unaware of that. Your strategy plan that you made available to
us has the national information campaign, and you have said that
it will start this autumn, possibly in a staggered way. What I
am interested to know is how exactly do you envisage that is going
to work? Are you, because of the evidence and the facts and figures
of diagnosis, going to have any very high profile campaigns to
really bring the message home to everybody, as well as, presumably,
specialist awareness campaigns, in targeted, presumably, publications,
targeted areas, like GP surgeries, or whatever, or what are you
going to do? Is it going to be a big bang approach, or is it going
to be a lot of different, more lower profile but more carefully
targeted campaigns, or a combination of both?
(Ms Hamlyn) I think it is a combination of both; and
I would probably say a medium bang campaign, really. We are talking
about the need for a sustained campaign. Some of the dangers of
having a big bang approach is that you have big bang and then
you stop; we want a sustained approach over a period of time.
We have also learned our lessons from some of those previous campaigns,
and, indeed, have done some quite thorough research about the
current, and particularly the 18-30 age group, which is really
kind of two groups, as you quite rightly say, it is 18 to early
20s, and particularly the issues of changing partners; for later,
it is usually the people settling down, and there can equally
be some issues in terms of sexual health at that particular point.
And it is that group that we are particularly talking about focusing
on, but as a mass advertising campaign, but appropriately targeted
in media that actually will be seen and appeal to that particular
age group, the 18-30 age group. But the age group under 18, we
are already targeting through the Teenage Pregnancy Programme,
again, in appropriate media; that includes using magazines, looking
at radio, potentially cinema, looking at ambient materials, we
are talking about an advertising campaign here and being quite
imaginative about how we can use public relations more generally,
associated with that. The reason I referred to learning some of
the lessons is that this particular, the young population we are
talking about now, the kind of approach of the kind of fear-based
campaigns is not going to work, nor will young people today appreciate
being lectured at, I think, from my evidence.
Mr Burns: Sorry, can I just be clear that I
heard you properly. Before you got on to the point about lecturing—
Chairman: Order. We have a division in the Commons,
so we will adjourn for exactly ten minutes.
The Committee suspended from 5.50 pm to 6
pm for a division in the House
Chairman: Colleagues, I think we are quorate,
so can we resume.
Mr Burns
102. You were in the middle of answering, before
we were so rudely interrupted?
(Ms Hamlyn) You raised the question about, and I referred
to, that we have learned some issues around, and people raise
this because they are worried that we might do a replica of the
Tombstone campaign; now it had its day, but I think some of the
issues about doing a kind of fear-based campaign like that is
that, if the threat, and the threat then was presented as an issue
both for the gay community and the heterosexual community, if
the threat does not bring out the same, to the realities of heterosexuals,
as indeed has happened in this country, then people start to distance
themselves from the issue. And, clearly, the evidence that we
have had from our research from the preamble to our campaign is
that people lived through that, and the heterosexual community
therefore do not see HIV as a threat, and indeed they do not see
it as a risk, but nor do they see it as, are not fully aware of
sexually-transmitted infections in general. So our campaign needs
to, certainly all the evidence is that fear, for the current generation,
that fear-based campaigns are not effective, that what we need
to do is a sustained campaign, we need to raise awareness, yes,
of HIV and STIs more generally, for the population as a whole,
and we need to promote condom use. So I think that is the context
of our campaign, particularly, as I say, it will be targeted for
the 18-30 population.
103. What actual evidence have you got that
fear does not work, or does not work as well as (persuasion ?)
?
(Ms Hamlyn) We have evidence from campaigns, actually
both here and abroad, I do not know if anybody else could qualify
that for me, in terms of research that has looked at what works
and what does not work. If it would help the Committee, I can
pull out the references for some of that research.
Chairman: That would be helpful, thank you.
Mr Burns
104. That would be, yes. Can I ask just one
other thing as well. Given that, in certain of these areas, more
and more evidence is becoming known, that was not known five years
ago, or whatever, how quickly can the Department, as a sponsoring
Department for health education, booklets and leaflets, providing
straightforward practical information and advice to different
target groups, respond to the changing medical-based evidence?
I raise this specifically because, I do not know if any of you
are aware, but no doubt other officials in your Department will
be aware, that the Department of Health has had some ongoing correspondence
with a number of Members of Parliament involving an issue that
one individual brought to these MPs' attention, which was to do
with HIV and oral sex. And it seemed to me, to be fair to the
relevant Minister, who was Yvette Cooper, at the time, that what
the Department said they were doing on the increased knowledge
of the problems, or the potential problems, they were responding
in what I certainly considered to be a reasonable way, though
there was a criticism from the person particularly concerned that
the timescale was not quick enough. And you have now, and I think
it is the Terrence Higgins Trust with their booklets, changed
the phraseology in that section, but it took some time, and the
Government argument was, you know, "We have got X tens of
thousands of these booklets, and it's a relatively minor part
of the whole area, and when they run out they will be redone,
replaced and updated." Is that a reasonable situation to
be in, because scientific evidence is changing the whole time,
and you cannot just pulp a whole section of booklets and advice
given out every time there is a change, unless there is something
really dramatic; and what you did was a perfectly reasonable way
to approach it, and that is the way you will continue to approach
this area, with increased medical knowledge?
(Ms Hamlyn) I think there are a number of points I
want to make. More generally, in our Action Plan, we have referred
to a review of leaflets in general, and I have already commissioned
that piece of work; that is looking at the availability and how
leaflets get used by people, users of services; and, indeed, it
is leaflets not just produced by, or funded by, the Department,
but through the professional bodies. And there are issues about,
all sorts of issues, in relation, that have started to come out
about that, about how people access that information, how it is
used within a medical context, and, indeed, where they need updating,
whether people, professionals, at a local level, are aware whether
they are using the most up-to-date piece of guidance. And we do
need to look at issues such as simple things that can be put down,
to put dates on documents, that we can have mechanisms to withdraw,
systematically, documents, where we need to, where we need this
change, and where we can make aware to professionals in the field
about a new document. Those are some of the measures that we are
looking at, more generally, on leaflets, to do, whether they are
ones that we produce directly or whether they are ones that are
funded through another organisation.
Siobhain McDonagh
105. I want to look at the area of contraception
and terminations. How will you address the staffing shortages
in community contraceptive services; and in the document you make
much play of having different sorts of facilities, both at GPs'
and contraceptive clinics themselves? But, in my own experience,
from my own area, which is a part of south-west London, those
community contraceptive clinics are closing, rather than opening,
and now almost exclusively, particularly in the less well-off
parts of my borough, which is the London Borough of Merton, GPs
really are the only people who are providing a contraceptive service?
(Ms Hamlyn) Yes, I have heard a number of examples
of that, and certainly through my visits across the country people
talk to me about the issues of difficulties of recruiting staff
into the profession, and being able to retain staff; so there
are a number of issues that we need to pick up, as part of our
overall Workforce Strategy. On the issues particularly of staffing
levels in community contraceptive clinics, there is likely to
be, if you look at the numbers in consultant posts, again look
at senior clinical medical officers and the numbers going to retire,
there are issues whether we are going to keep up with the numbers
that we need to have, in terms of consultant posts and associated
specialist posts. And the Royal College, the Faculty is pursuing
that issue, looking at additional training programmes, looking
at how that can be addressed. Also, this year, we have funded
the Royal College of Nursing to develop a distance learning pack
for nurses, and, of course, not everything in community clinics
is done by doctors, and again there are the skill mix issues.
Now having a distance learning pack will help, but clearly it
is not going to solve the whole problem. And I think it comes
back to the wider training strategy that we intend to develop,
which is intended to look at all professional groups, it is intended
to look at what is available, in terms of training, intending
to look at the issue within the workforce study, the issue of
training posts, and the issue of different types of staff that
can be used for different purposes. There are very good examples
across the country where you do not need doctors to run a contraceptive
service, you can have nurse-led services, we have the role of
pharmacists now providing provision of emergency contraception,
and you have examples of services, indeed, where youth workers,
social workers can have a role in providing advice, and, indeed,
the distribution of condoms. So I think there is a range of different
issues that can start to address, quite rightly, the problems
that you are mentioning.
106. And how will you address the current iniquity
of access for termination of pregnancy services; here, it has
got particularly for rural populations, but I have a case with
me of a GP who has recently written to me, again, in south-west
London, concerned that his patient had to wait in excess of five
weeks for a termination at a major London hospital?
(Ms Hamlyn) Through the strategy referred to, the
issue of actually trying to address the issue of access to abortion,
and indeed we are setting a standard that PCTs need to ensure
that women who meet the legal requirements for abortion have access
to abortion within three weeks of their first appointment. That
is a standard that we expect PCTs to start measuring against,
and, indeed, our intention would be that by 2005 that standard
is fully adhered to.
107. May I just ask you a question about that
target. Surely, the answer then will be to delay longer before
you get your initial appointment; if it is only three weeks after
you have seen the consultant?
(Ms Hamlyn) It is the first referring doctor, we are
talking about.
108. So the GP?
(Ms Hamlyn) It is three weeks from the first referring
doctor is the issue. Now we do know that there are issues; this
standard is intended to address some of the issues of waiting
that you are talking about, and, indeed, some of the issues where
local commissioning policies can be quite restrictive, and we
do know examples, like you quoted yourselves, we know a particular,
difficult issue for the younger age group, young teenagers tend
to present late and then it becomes a real, big issue, and particularly
if they have got to travel distances. So I think we are very serious
about addressing this as a particular standard, it is in our Action
Plan. Through the Commissioning Toolkit, we will be incorporating
good practice, in respect of abortion services, again to provide
easy access and to be obviously the standard that we are setting.
Julia Drown
109. Just carrying on from that, even three
weeks is quite a long time to wait?
(Ms Hamlyn) It is a maximum. Clearly, one of the debates
that people have had is that, for some women, they need the opportunity
of thinking about whether it is the right decision for them. I
think it is a balance between not rushing women straight in, but
actually having a reasonable time. It is in accordance with the
Royal College of Obstetrics and Gynaecology, so it is a guideline
that is consistent with the Royal College.
110. But, for those who have firmly decided,
would your aim be something much better than that?
(Ms Hamlyn) I would hope that they have a very smooth,
easy access actually into services, yes, when they want a service.
111. The other thing I wanted to ask about was
encouraging better methods of termination, safer methods that
do not involve general anaesthetic; what are you doing to encourage
that, and will you be funding any such facilities being developed,
particularly in Primary Care facilities?
(Ms Hamlyn) In our Action Plan, we have referred to
our pilots, of looking at termination of pregnancy in non-traditional
settings, but within the law, and also looking at improving early
termination, which avoids the issue of medical complications,
in terms of later termination. So those are pilots that we would
be taking forward, as part of the Action Plan.
112. And we have got those details in the Action
Plan?
(Ms Hamlyn) It is in the Action Plan.
John Austin
113. I want to come on to toolkits and piloting
in a moment, but can I just go back to this issue of mainstreaming
versus ring-fencing, and ask, what is the future of the AIDS support
grant that is made to social services departments for the care
of people with HIV and AIDS?
(Ms Stanier) We are currently reviewing that grant.
We do feel, in particular, that there is a need to simplify its
administration, because at present we ask local authorities for
estimates and then we allocate funding on the basis of those estimates,
and then we do a second process in year. But there is certainly
scope for simplifying those procedures.
114. But is there a risk that it may get lost
in the just general grant allocation, resource allocation, to
local authorities, or will it still be specific?
(Ms Stanier) It is the case, as you are aware, that
there is a general move towards more mainstream provision of funding,
both for the NHS and local government; so that certainly is a
possibility, but the review will be concluding later this year.
115. But there will be systematic and careful
monitoring of what happens in local authorities, if you change
the system?
(Ms Stanier) We would approach it in exactly the same
way as we have for HIV mainstreaming, to make sure that proper
management arrangements are in place.
116. But you have referred elsewhere, evidence
has referred elsewhere, to somewhat cumbersome data exchanges
between the Department of Health and health authorities; what
steps have you got to improve that, and what is the role of the
Health Development Agency?
(Ms Stanier) If you are referring, in particular,
to the AIDS Control Act returns, it is equally the case that we
are in the process of reviewing those returns, with a view again
to make sure that we are only asking for information that we really
need, and that we make good use of that information, for example,
by collating it at a national level and actually publishing the
findings. The Health Development Agency do not have a particular
role in that process.
117. So what is their role?
(Ms Hamlyn) The Health Development Agency, we have,
in fact, commissioned them to pull together the best possible
evidence of what works, in respect of HIV and STI prevention,
and that is very much in terms of their role about drawing together
evidence, not new research but reviews, and that evidence will
be made available to the field.
118. Can I come on to the issue of the implementation
of the strategy and the toolkits, which you mentioned, which,
clearly, you see as critically important for the success of the
strategy. To what extent have the providers and patients been
involved in their development, and how will they be piloted to
ensure that they are valid?
(Ms Hamlyn) In both cases, in terms of the Health
Promotion and Commissioning Toolkits, our date of completion,
is set out in the document, so we are not talking about until
late summer or autumn to publish those, so it is not the case
that we have a document now. During the consultation period, the
idea of having a Commissioning Toolkit received overwhelming support,
and the process by which that is being developed will involve
a number of people from the field, who are already involved, in
terms of professionals in the field. As I have also referred to,
in the Action Plan, it is the intention to set up ongoing methods
for user involvement, at a national level, and there are currently
arrangements by which we use various mechanisms for involving
through key national voluntary organisations, in terms of user
involvement, currently, but we need to substantiate that. And
those are the kinds of mechanisms that we will want to use, in
the development of both these Toolkits, and indeed any further
guidance that we want to produce.
Dr Taylor
119. We have talked a bit about PCTs, and the
tremendous responsibilities being devolved to them, and I am terribly
worried about them, particularly those that have only just started
this year, and whether they are going to have the capability of
really doing everything. Now do you have plans actually in place
to ensure that PCTs are equipped? In your Implementation Plan,
they have to identify a sexual health and HIV lead, with appropriate
level of seniority and public health expertise. Are there enough
of these people around, and, generally, what support are you going
to give the PCTs with this crucial role that they have not actually
had before?
(Ms Hamlyn) In every PCT there is now being appointed,
and the vast majority have been appointed to date, a director
of public health, and within every PCT there will be health promotion,
people with a health promotion background, previously who had
worked for health authorities, and there may be arrangements whereby
one takes a lead on behalf of PCTs. So there are the people there.
We have asked for every PCT to identify a lead, we have not got
a full list of those at the moment, but we intend, obviously,
to get a full list of those, and the intention will be to really
create that into a network, a network where we can ensure that
they get all the up-to-date guidance and information, that we
can build in through seminar programmes to develop their own skills.
We are looking at what kind of support can be made available at
a regional level, through the regional public health groups. The
Commissioning Toolkit that I referred to earlier, our intention
is to have seminar programmes, to invite these leads to, in the
autumn, once that is available, and there will be similar programmes,
seminar programmes, for the Health Promotion Toolkit. So we are
building in training and development as part of really developing
that capacity, which we feel is key for the success of the strategy.
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