Examination of Witnesses (Questions 160-179)
MS ANNE
WEYMAN, DR
SARAH RANDALL,
DR KATE
GUTHRIE, MS
JANE THOMAS,
MR IAN
JONES AND
MS LIZ
DAVIES
WEDNESDAY 10 JULY 2002
160. Yes.
(Ms Weyman) The issue of Chlamydia screening is really
the time that it is going to take to roll it out. There is obviously
the resource question about having sufficient trained people to
do it, having the laboratory facilities to process samples and
things like that. Partly that is the question, also, of how rapidly
you put the resources in. Certainly it has taken a very long time
for this country to get to the stage of having Chlamydia screening.
They have been doing it in Scandinavian countries for 20 years
or more and it would seem that it has had an impact in those countries,
yet we are only just now starting to do it properly. I think our
concern has been that here is a situation where there is a preventable
harm, women are contracting Chlamydia, they go on to get Pelvic
Inflammatory Disease, they develop infertility as a result and
this can be prevented. It seems really horrific it is not happening
quickly to prevent as many cases as we possibly can. I think it
is really making a bigger commitment, more upfront is what we
would like to see.
161. Could it be done as part of the so-called
screening programme or would that not be a good way of doing it?
(Dr Randall) I was one of the two pilot sites which
did the original Chlamydia pilot and we are now doing the follow
on for that. Portsmouth and the Wirral were the two sites. We
are now doing the follow on to look at how often these people
need to be screened because it is all right doing one test but
do you test everyone every six months, one year, five years or
whatever, so that needs to be answered. Yes it could be tied in
with cervical cytology and there are various new tests being looked
at, at the moment, something called thin prep where you take cervical
cytology cells but you can use that same preparation also to perhaps
look for Chlamydia as well. The technology is out there only,
unfortunately, of course, the first cervical smear is not until
you are 20 to 25 so that might be a bit late when we have been
picking up people who are 15-16. It goes back to the whole business
about the concept of sex and using condoms or not having sex at
all and talking about it really.
(Dr Guthrie) If you look at the young people who we
are talking about, young people buy into screening like that.
We got some free urine tests for Chlamydia back in the days when
we were doing cervical swabs. We only had 200 free tests in a
pilot study, then it stopped, and yet they still came and queued
at the door, aged 15-16, saying "I want that test you have
got". Young people are right into screening for Chlamydia
really quickly. There is not a problem of selling it to the community
we are talking about, the problem is not with those who need the
help, the problem is with us as service providers.
(Dr Randall) And with funding.
(Dr Guthrie) Obviously with funding.
Mr Burns
162. Can I just ask one question, just going
back to your comments on education, Ms Weyman. You said, and you
admitted it was controversial, about education and the primary
school sector which, as you will be aware probably more than many,
causes a great deal of concern to a significant number of parents
in this country. What surprised me slightly in the answers was
you seemed to concentrate on education in schools but there was
not a lot said about what many families might think was their
responsibility at that age, to set the pace, move the pace with
their children as to what they should or should not know or be
taught about sexual matters and sexual education at that age.
Why did your answers seem to concentrate more simply on the school
system rather than the parents because many parents in this country
would possibly take the view that at that age their children should
get what sex education they feel is appropriate from the home
rather than the teacher?
(Ms Weyman) We do not see it as an either/or because
parents are very, very important. What we find so often is when
you ask older children what they would like to happen is they
will say "We would like our parents to talk to us about sex"
and parents say "We would like to talk to our children about
sex" but actually it does not happen and it is a difficult
area. We do need to support parents to do that and from an early
age for them to do that. The evidence is that in those families
where sex is openly discussed children start to have sex later
and they are more likely to use contraception when they do have
sex. The family is very important. They are two roles, they are
complementary roles. The concerns of parents I think can be much
addressed if schools work with parents and consult with parents
and show parents the materials they are going to use and discuss
these issues with the parents. Not all children have that sort
of relationship with their parents and they need to get information
also
163. I accept not all parents do but would it
not be better possibly the other way round where instead of the
parents talking to schools about how the schools are going to
do it for primary school children, the schools talk to the parents
about how the parents are going to do it?
(Ms Weyman) Interestingly we have been doing quite
a lot of work with parents and one of the projects we are going
to be doing is working with schools to work with parents, particularly
primary school children. I still do not think it is a one or the
other, I still think it is both. I think there is a lot going
on in schools which parents never get to know about, what their
children are talking about, what they are talking about with other
children who are getting other messages from all sorts of places.
Parents, however much they are doing outside the school, they
are not participating in that part of the education or the misinformation
that children are getting. So the school does have a very important
role to play and it enables children to get to think about these
issues and to talk about them in a way.
164. What sort of age do you think it is appropriate
for children to start talking about these issues?
(Ms Weyman) For me, I think children who are very
young.
165. Like?
(Ms Weyman) Four or five.
166. Talking about sexual activity/sexual matters?
You think that is appropriate? Most children probably have not
given it a moment's thought at that age.
(Ms Weyman) Children ask all sorts of questions at
a very early age and they are interested in aspects of their lives
and other people's lives. I know many people—you may not—who
do talk to their children and explain to them about what would
be called the "facts of life" when they are very young.
Mr Burns: I understand that and I do not want
to prolong this but I am thinking back from personal experience.
Neither of my children aged four or five were discussing or enquiring
in any shape or form things that probably come within the definition
of sex education.
Jim Dowd: They were not telling you.
Mr Burns
167. I do not think they were telling each other
either.
(Ms Weyman) I would like to say something about that
because we give children signals about what it is they may or
may not talk to us about at a very early age. One of the most
powerful signals about sex being a subject you do not talk about
is the fact you do not talk about it and parents often wait for
their children to raise it as an issue, and if they do not raise
it as an issue the assumption is that they are not interested.
When we think things are important we talk to children about them.
Whatever you are doing in your family or in the school around
the issues that you are talking about, you are giving very strong
messages, particularly when there is so much discussion about
these issues in the broader world which children are picking up
all the time from when they first can understand what is going
on on the television. They understand much more than most adults
would give them credit for.
Dr Naysmith
168. I want to go back something that sounds
a bit tame after that. It was something Anne said and it was picked
up by Ms Thomas and Dr Guthrie about the question of contraception
and where it should be delivered, whether it is delivered at the
GP surgery or in the specialised clinics. A few years ago there
was a big fuss about this. I am not sure whether it came from
the Department of Health or where it came from, but there was
a big push to move it towards surgeries generally and towards
GPs and primary care and clinics were closing all over the place.
Firstly, was that a bad thing? I would suspect myself it was a
really bad thing. Secondly, is it still going or has it been resolved
in a more sensible way with the necessity of having choice?
(Ms Weyman) From what we understand, the pressure
is still there and there are still clinics—
169. You mentioned resources earlier on and
I thought at the time it was more than resources and somebody
was pushing it in the background.
(Dr Guthrie) It was political, due to the shift to
fundholding.
(Ms Weyman) There has always been the view that there
should be choice and there should be open access services that
will commute, but what that means in practice varies very much
from area to area and the fact women can go to their GPs was seen
as providing the service. In the Strategy it defines three levels
of service and the fact that these should be available to be used.
However, only some of them will be provided in general practice,
so the idea would be that if general practice cannot provide the
full range of methods, it would be an entry point so that women
could get a full range of methods, but that does require there
to be those services that can provide that full range of methods
to be available and, as I say, we are seeing in some areas clinics
are under pressure and they are under pressure for two reasons.
One is because of not wanting to put the money in at the local
level and the other reason is the inability to attract staff—and
that is because it is not necessarily an area where the career
structure for doctors is very good. We as an organisation are
not there to represent professional interests but we recognise
that if doctors are not able to pursue their careers in a particular
area of work then they may not be attracted to go into it and
the day has passed when you had quite a lot of women doing sessional
work in family planning. That is changing. If you do not have
clinics, it reduces the opportunity to train new people because
that is one of the main training grounds for people to come into
the service. It is a problem and it is something that I do not
think the Strategy was necessarily aware was as big a problem
as it is.
170. Presumably there must be a problem with
younger people preferring to go to clinics than going to their
own GP or the family GP? Is that right?
(Dr Randall) There has been a problem here because
in a lot of areas clinics were closed and we were told they will
not see anyone over the age of 25. That left services for young
people and to get back to the business of training, if you are
expecting all the normal people to go to GPs and yet you have
got nowhere to train those GP and if they come to clinics they
are only seeing youngsters, then this is a disaster area. Although
some GPs are very interested in the subject, they are generalists
and a lot of GPs do not want to do it. It has been a disaster
in a lot of areas that clinics have closed. Those that have been
left open have increased demands. Certainly around my area you
have some clinics which are totally swamped. They have got perhaps
four clinics trying to deal with what was originally a week's
worth of clinics foreshortened and whereas perhaps GUM services
have appointments and can show an increase in their waiting lists,
a lot of family planning lists are non-appointment so all it means
is that you sit there until you have seen all the clients. You
might get 30, you might get 70, and you are there until they have
gone.
171. It is still a problem?
(Dr Randall) It is still a problem.
(Dr Guthrie) I think you are right. Historically as
we become competitive for service provision between community
services and general practice/primary care, it is all primary
care. The funding streams were different; the funding streams
changed and it then became fundholders and whatnot so it becomes
even more competitive for funding streams, and that is where we
lost clinics. Hopefully, that has become historical but the spectre
is still there when there is no new money coming with this Strategy.
The answer to your second question of who should be providing
the answers is we have got an opportunity to be really adventurous
and innovative when it comes to service provision because services
should be provided by the right person in the right place for
the community for which you are providing. It is very different
in a community that is very socially deprived if you have got
a lot of refugees and asylum seekers and young people. The focus
is very much on outreach services and services in schools, next
door to schools, church halls. I do not care where services are
delivered as long as the delivery is appropriate. In some place
else you might have got very few young people, an area to which
people will retire or the commuter belt, and you are looking for
a completely different sort of service. So there is no blanket
answer to that. If there is a blanket answer the answer is know
your community and then do what is appropriate.
(Dr Randall) Also have the appropriately trained people
wherever they are. I think that is the answer.
Andy Burnham
172. Following on from Doug's question there,
am I right to infer that you think the services are not adequately
sign-posted or advertised at the moment, that people would rather
it be word of mouth and that is how people hear about the service
at the moment?
(Dr Guthrie) Personally I think nationally it is extremely
inadequate. It is progressively becoming the "poor cousin"
in terms of health care provision.
173. Is that because young people, thinking
about them particularly, would much rather arrange these things
for themselves and get hold of the contraception in a way that
they feel comfortable with rather than going to the Health Service,
which would not be their first port of call. Or have social habits
changed?
(Dr Guthrie) Young people have to know where to go.
It is one of the best kept secrets from young people. You really
have to work quite hard if you are young to get information/access
services. I have got young teenage children. They say, "Our
friends come to ask us, and if we were not your children we would
not know where to go either." This is because the whole health
care circuit has been designed by people like us who are far too
old, and until young people tell us what they want, which the
Teenage Pregnancy Unit has done very well on because they have
got young people asking young people what they want unless we
ask.
174. So you would favour greater advertising
amongst young people, possibly in schools?
(Dr Guthrie) We have to ask the users what they want
and then deliver it. We do not know what they want and where they
want it.
Jim Dowd
175. How do you attract people that are not
users?
(Dr Guthrie) There are the obvious users, kids who
do come along and they speak up. What was very difficult to get
at was the potential users who do not come along so how do you
get information to them? That is why you have to get into a participatory
appraisal which is a way of going out into the community and asking
the community what they need by more indirect methods. Otherwise,
it is us setting up services which we can only hope are hitting
the right targets.
(Dr Randall) Could I add, also, there was a problem
with the schools because we could not advertise specific services
in schools, that was considered not correct, whether that will
change—I mean if schools can be more open about advertising
local facilities or they have access to be able to go to find
out from schools, because after all that is where they are, then
that would help.
176. Sure.
(Mr Jones) I would like to add, I agree with everything
my colleagues have said in relation to advertising for contraceptive
services and the like and the emphasis on teenagers but I think
there is a problem overall about the openness of the subject which
is what Dr Taylor was on right at the beginning and that is where
I think, also, this is a huge opportunity for us to normalise
these services as a routine part of health care. Can I just make
the point about teenagers where, rightfully, we are concentrating
on them both within education and in signposting and service provision.
Please bear in mind in relation to access to abortion care 79
per cent of all women who had an abortion last year, or in the
year 2000, were not teenagers so it is a problem with adults not
just with teenagers.
177. Can I say as a Catholic married to a Dutch
person I am slightly torn in two directions on these issues. Actually
while I can see the logic of a lot of what you say, if you do
not mind me saying I think you would favour more moves towards
the Dutch model, so to speak. They seem to have it right. I believe,
also, you cannot push the British character in a way that people
would not feel comfortable with. I think, personally, some of
the successes that they have had in that country would go further
than the British public, I would say, would be able to go. Would
you say I am totally wrong and an old fogey for saying that?
(Ms Thomas) The Dutch have got it right because they
are comfortable about talking about sex. I happened to grow up
in Scandinavia, the Scandinavians are very comfortable talking
about sex. They have adverts in cinemas and things about condoms,
you have to normalise it. People have to talk about it, they cannot
meet contraception or try to use it for the first time when they
are having sex because it is not going to happen. You have got
to make services—whether it is about infection or about
contraception—easier to access and people have to know about
them and know where to go and be able to get there before they
have sex and that way you prevent some of the problems. People
are not having more sex in this country they are just doing it
badly.
178. They are not having more. When we came
back from Brussels, the trend here is that young people are having
more partners and they are sexually active at an earlier age and
while that is a similar trend abroad, I think we picked up the
case that it is more the case here linked to an alcohol culture,
is that not the case?
(Dr Guthrie) It is partly alcohol but it is partly
because they are ill-educated. We keep coming back to if you are
talking about young people, they are ill-educated, their parents
are-ill-educated. They are in an educational environment which
is in itself ill-educated, that is what the research evidence
has shown. That is why Holland and other parts of Europe are different.
Sexual education is not just about having sex.
179. Let me put back to you the absolute opposite
view. Spain, the Catholic countries, have a better record than
we do, why is that?
(Dr Guthrie) Because they have a different cultural
environment.
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