Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 180-199)



  180. Why is it right to go that way rather than go a different way and say "do less"? They would argue strongly they have got it right, a culture of no sex before marriage.
  (Dr Guthrie) Certainly in countries which have an environment of—maybe a new word—religiosity, is the word they use, there is a different attitude towards sex, whether it is Catholic or whether it is Protestant, whatever faith it is, if it is a very religious country they do have a bit less of a problem because that is the culture of that country. The UK does not have that culture either.
  (Ms Weyman) The UK culture is a very confused culture.

  181. Indeed.
  (Ms Weyman) On the one hand you have this "We cannot talk to children about sex, we might approach on their innocence" which I think is a very strange concept because why is sex somehow associated with guilt. We have that aspect. Then you have all this terribly overt sexual imagery, sex selling products, the total preoccupation in a lot of the media with the sex lives of people who are well known. It is a really confused environment in which young people, and the rest of the population, are engaging in their sexual relationships and seeking advice to prevent pregnancy and to prevent infection. I was interested in your comment about whether the things I was saying go far beyond where the British culture is now. I think the difficulty is how we judge where the British culture is at and where people are at. If you believe what you read in the newspapers, particularly some of them, you get a very different view from what people actually think. I think the example here that I would use is around attitudes to abortion because when you do the opinion studies you get, Ian quoted 60 per cent, some studies have shown higher percentages of people who are very accepting of abortion but if you read the popular press you would think that was not the case at all. You cannot judge it on the shock, horror, hysteria that we read in the press. Most people are a lot more sensible than that and a lot of parents would like to be able to talk to their children and would like their children to know but they do not know how to do it because they have no role model themselves because their parents did not talk to them.

Sandra Gidley

  182. Does Ian want to respond?
  (Mr Jones) Could I make one point. I agree entirely about the concerns we should have about sex education and providing better information but with the best will in the world if we introduce a 100 per cent effective sex education programme from tomorrow we have still got some ground to make up here and it is going to be some time. As a health management person here, I am concerned that we do not lose this opportunity in the Sexual Health Strategy to improve the delivery of services which we need now as opposed to saying "Let us get the education right first", we need to get the services right so the education can follow through as well.

  Sandra Gidley: What has been very striking throughout this inquiry so far is the first panel was all female, I think uniquely so. We have a token man here today.

  Julia Drown: Most welcome.

Sandra Gidley

  183. Yes, most welcome. We had predominately females we spoke to when we had our visit to Brussels. When you are accessing services I think there is very much the feeling that this is girls stuff and there is a lot of pressure, I think, put on the female to sort out her contraception and all the rest of it. Where do young men fit into this? It seems to me they should be taking more responsibility rather than less. Family planning clinics seem to be geared towards the female, is there something which needs to be done here or are there young men's clinics out there which are not available?
  (Dr Guthrie) Historically you are absolutely right, it seems to be the British thing that it is the woman's responsibility. When you do have a young man coming along with his partner to the clinic, whether it be a hospital clinic or a community clinic and you say "Bring your partner in" she says "No, no, leave him out there" and he says "No, I am not coming in, that is another British thing. When I have been to Europe, and I have been to Holland to see how they do things over there, they are just amazed at our approach". They say "Are you surprised you have got problems because you are only talking to half your population?" There is a culture here of men not having to take responsibility. The Dutch deal with couples. Of course if you deal with a couple, if it is the woman who has got a problem with her contraception or has an unintended pregnancy (a) 50 per cent of it is something to do with the man and (b) he may learn something so he goes into another relationship and takes some knowledge with him. It is something we do very badly here, we know we do very badly so we are trying to be more inclusive of men and have services which are appropriate and attractive to men.

  184. Are there any examples anywhere around which may be interesting for us?
  (Dr Randall) There has been a lot of outreach work with young people with clinics sited in non-health centre premises. They might be youth clubs or whatever and they often have youth workers there as well who have gone and worked with the young people and they say, "Come along on Tuesday, you will see me." That is attracting quite a lot of young men but an awful lot of our abortions are older people over 20 and it is a question of how we get those men in. I think that is incredibly difficult. Again, it is all to do with stigma. It is okay for them to brazenly walk in but they are not accountable.

  185. Something that occurs to me just as a supplementary to throw into the pot—you can get your oral contraceptives free on prescription, you cannot get condoms free on prescription; should that be changed?
  (Ms Weyman) We would like to see free condoms. One of the issues about the involvement of men again comes back to greater integration of services across sexually transmitted infection services and contraception because men do go to GUM services. Four or five years ago we did a project working with professionals in GUM to get them to raise contraception issues with the men they were seeing. If you have got a much more joined-up service, particularly if they are being provided from the same location, it becomes much easier to at least meet men and talk to men who are coming into a sexual health service about contraception. I know that we do not want to talk only about education but that has also been the case in sex education. It has very much in the past been provided by women and focused on girls, and boys were seen as the problem. That completely alienates them and now there is beginning to be a change towards taking the needs of young men on board and giving them the sex education they need as well. I think that we need to try and look more imaginatively. When a woman comes to see her GP, the GP may very well ask her about contraception or might ask her about these issues if he believes she is likely to be sexually active. He probably would not ask a man in the same way and yet why not? These are about professional education and prejudices and stereotypes and what you say to whom or what questions you ask people.

  Mr Burns: We will move on rather than give a disproportionate amount of time to this area. Dr Naysmith?

Dr Naysmith

  186. I am sorry, Chair, it is something we have touched on already, which is inequalities and anomalies in the services geographically and also sociologically as well. The Strategy states that the accessibility of contraceptive methods that are available varies very widely. What do you think the reasons are for this? We touched on this a little earlier so if you could talk maybe not so much about the main reasons but what we can do about it.
  (Ms Weyman) We talked about the reason to do with funding and training doctors and what they can provide. There is an issue about knowing the facts because the data collection we have is not the same across what happens in clinics and what happens in general practice and we have very little information about what is actually happening in general practice, what methods are being provided, and really if we are going to look at inequalities and look at whether the Strategy works, we need to have a much more consistent collection of data across the different groups.

  187. I imagine there is very little cross-referencing. The National Health Service is notably bad even in terms of data transfer from GPs to acute hospitals. I imagine this area is even worse.
  (Ms Weyman) It is not necessarily a question of sharing of the data; it is a question of collecting data in general practice and returning it. Family planning clinics make returns about who they are seeing and what they are providing. GPs are not doing that. GPs get a fee for providing contraceptive advice. At one time you used to be able to get information about how many women were being seen in general practice. You cannot get that information any more.

  188. Why does that not happen any more?
  (Dr Guthrie) In some areas nobody cares.

  189. How can you make them care if you think it might be valuable?
  (Dr Guthrie) You have to make them care. The Strategy has to get into monitoring and evaluation. That has to be, I am afraid, top down. If you look at the way it is laid down—

  190. So more direction from the centre, more red tape? The things doctors particularly are complaining about?
  (Dr Guthrie) No, service leaders like Sarah and I are very motivated to provide a good service in our areas. It is about working with the commissioners of the service to know what are your areas of need and to provide the services. It needs to be given the power to do that.

  191. Does anybody else want to come in?
  (Dr Randall) There are still a lot of services out there which have no lead at all. We have 171 community services but a quarter of those have no medical lead whatsoever so those services are probably led by a nurse or manager, so where are you going to get your direction from in those services? You do not have a lead so your business about standards and helping has to come from somewhere. We would hope it does not have to come from as high up as central government. If it is going to come from people who are going to lead the service and help GPs there has got to be a local leader there, and some areas do not have that. That is back to funding, training and back to the same old things.[14]

  192. What about the three levels of service that are mentioned in the Strategy?
  (Dr Randall) There will be some areas which will find it very difficult to run level three because they have not got the consultant or senior lead doctor there to do to it, so those GPs could find it quite difficult.

  193. What does that mean for staff? Does it mean increased staffing, improved staffing, more training?
  (Dr Randall) It all goes back to how we get consultants, which is a training issue because family planning and contraception is not seen as a specialty whereas GUM is, so training people to become consultants in family planning is actually very difficult. You have to go by the obs and gynae route whereas for GUM you go up a different route. Consequently it means that at the moment we are very short of consultants and there is no easy way of achieving the numbers that we need.

  194. What about the putting together of GUM and contraception? They have evolved quite separately but the Strategy suggests bringing them together and integration. Is that a good or bad thing?
  (Dr Guthrie) It is very welcome. It has been a ridiculous divide.

  Dr Naysmith: I would have thought some of you would have thought it was a bad thing.

  Jim Dowd: You were wrong.

  Dr Naysmith: I was wrong.

Siobhain McDonough

  195. The new GP contract suggests that family planning will be included as additional services. How will this impact on current service provision and appropriate delivery of contraceptive services across the NHS?
  (Dr Randall) We do not know is the answer to that because we are not sure what is going to happen to the pot of money that went out to the GPs for their item of service payment. Is that pot of money still going to be there for contraception or is it just going to disappear? There may be some GP practices who will say, "Yes, we will continue to provide contraceptive services"; others might say, "If the money is not there we are not going to provide it." At the moment they get quite a lot of money, they get about £60 for fitting IUDs. For some that might be quite an incentive to carry on doing so. If that is removed where are women going to go to get their IUDs or coils fitted? Again, that could possibly put pressure on local community services. We do not know until we know how the new contract is going to pan out.
  (Ms Weyman) I agree with what Sarah says. We want to be sure that that pot of money is not lost because it is something that is being spent on contraception at the moment. In the GP contract, from what I have read about it, there will be standards attached to those additional services in return for payment, although the amounts of payment have yet to be determined. It seems to me it is really important that there is a link between the Sexual Health Strategy and the people at the Department of Health responsible for the Sexual Health Strategy and whoever is negotiating those packages and how they are going to be implemented. It tends to be that the GP contract is negotiated over here and the Strategy over there, and it is just not going to happen if that is the case. One of the things that we have always been really concerned about is that the fee is paid regardless of what is provided and regardless of whether the doctor is trained to provide anything. The doctor can get a fee by just asking a woman whether her contraceptive needs were taken account of at the moment. The new contract could be a real opportunity to ensure that there are good standards in general practice and there is also the issue of the PCT having an overview of what is going on and making sure there is sufficient provision so that if the GP practices in their area are not providing the service, they are making sure that the investment is going in to providing it through other means. It could be that these changes could be a real opportunity for improving the quality and delivering the standards as set out in the Strategy or it could mean that we get less than we had before. I think what is important is that it is put in place, and we make sure it is the former and not the latter.

  Dr Taylor: Can we move on to the place of PCTs.

  Mr Burns: Hang on. I think we will let Siobhain carry on with her questions first.

Siobhain McDonagh

  196. Can you give your views on the training requirements for specialists working in the field of contraception and for basic training in primary care and community clinics? In particular, do you feel that improvements need to be to GP training to ensure the consistency and quality of GP contraceptive provision?
  (Dr Randall) Can we talk about GP training first. At the moment, the GPs would say that what their trainees learn in their three years' vocational training is sufficient to provide them with all the knowledge that they need for contraception. There has been a lot of debate with the Faculty of Family Planning who organise specialist training, if you like, about whether or not GPs need to take the Faculty's Diploma. I think that is a debate that you can have. As long as GPs receive adequate training to provide level one service then I think that could be acceptable. The problem arises when GPs want to offer other services, then you need to be looking at specialist training in how to fit an IUD. I am sure we would all want to think that our GP has been taught how to fit a coil before they go ahead and do so. There is no need for that to happen at the moment. Women are not going to go to their GP and say "Excuse me, how many coils have you fitted in this last year" before they decide whether or not they are going to let that person do so. I think we need to get the Faculty of Family Planning and the General Practice Colleges together and sort out some basic training. I think at level two we are looking probably at the Faculty to continue perhaps its specific training for things like implants and coils. Then, again, it goes back to Anne's topic about tying in, if you like, standards here, whoever provides these services is trained to do so. I think that is where I would come from.
  (Dr Guthrie) Higher levels of training. There are two issues. One is you have to have an adequate number of doctors trained to deliver the service. Right now if you look at workforce planning, the Royal College of Obstetricians and Gynaecologists, where ultimately most of the consultants come from in this field, there are a very small number of specialists coming through. That is a big issue. There is a reduction in total numbers of trainees and of the numbers of trainees available, a very small portion are specialising or sub-specialising in sexual reproductive health. The second thing is a lot of the services are delivered not by consultants but by what are called career grade doctors. The Faculty of Family Planning does have a training programme for career grade doctors, it is a modular training programme over three years. We have looked very carefully at training, not just training but also maintaining standards so not only do you want to know that your doctor has been trained to fit your coil but he is keeping his skills up to date. We do have standards for training at general practice level, career grade doctor level and consultant level. The training is there but unfortunately the numbers of doctors are not coming through. It is partly financial and it is partly a numbers game at college level.
  (Mr Jones) The infrastructure that Kate described as being there and the standards being there for training in contraceptive and other work, is notably absent in terms of abortion practice and the skill base for termination pregnancy which I referred to earlier. There is a significant issue there in relation to the capability in future to deliver the targets that have been identified within the Strategy for abortion care, if there is a real commitment to do that, with the lack of skill base which exist at the moment.

Andy Burnham

  197. Just a very quick point, again about access to services. What would you say to the assumption that by making people more aware of the services which are available at their GP's clinic or within the local community, particularly young people, that would encourage them to become sexually active younger? Is there any evidence internationally that would back that up and if there is, should we be worried?
  (Dr Guthrie) There is no evidence for that. The World Health Organisation, and all the big authorities have gone into this, there is absolutely no evidence. The only evidence there is is that properly conducted education programmes and service delivery retards the rate of starting sex.

  198. Part of the reason in Holland—
  (Dr Guthrie) They become sexually active later.

  199.—you would say that is linked to the openness of advice?
  (Dr Guthrie) Education, environment and service delivery.

14   Note by witness: Manpower planning/manpower census available from Faculty of Family Planning. Back

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