Examination of Witnesses (Questions 420-439)
MONDAY 18 NOVEMBER 2002
MR NICK
SPRINGHAM, MS
EVELYN ASANTE-MENSAH,
PROFESSOR MIKE
KELLY, MS
KAYE WELLINGS,
MR SIMON
BLAKE AND
MRS LINDSAY
ABBOTT
420. When was there no service for Northumberland?
(Mr Springham) As far as I know there has never been
a GU service in Northumberland.
John Austin
421. I should add it is easier to get to Newcastle
than to get to somewhere else in Northumberland.
(Mr Springham) I think that is true. It is being looked
at, I have to say, they are not blissfully going along with their
heads in the sand, as with Gateshead. What is true is with a large
rural area it is easier to get to Newcastle than it would be to
get from Hexham to Morpeth, for example.
422. Moving on to health promotion, again looking
at Nick I am afraid because you are on the coal face with PCTs;
what is the range of health promotion strategies that your PCT
uses at the moment?
(Mr Springham) It is a very big question really because
there is a huge range. Obviously I think it is very important
that people have the information that they need in order to look
after their sexual health. That was clearly stated in the national
strategy that information is an important part of sexual health
promotion. One of the difficulties is perhaps it is the easy bit
really to tell people, "These are the facts. This is what
you need to look out for", etcetera, etcetera. The difficult
bit is to go beyond that because people also need the skills to
be able to use that information and the understanding to be able
to use that information. To just to tell people, "Don't do
this or do that or do the other" we know that is an important
first step but not very effective. Most people in this country
know that smoking is bad for you but we know there are a lot of
people who continue to smoke. People need the skills to be able
to do that. The skills around sexual health could be having the
assertiveness to be able to make the choices that they want to
make, whether that is saying "no" or whether that is
saying "yes but" or "yes if", etcetera, etcetera.
This is an area where there is not a huge amount of time and money
invested into to provide young people and older people with the
assertiveness skills to be able to negotiate in relationships.
Let's face it, sex on your own is not particularly dodgy in terms
of targets but with sex with somebody else you could get sexually
transmitted infections, you could get pregnancies you did not
want, etcetera. So sex takes place in the context of a relationship
with somebody else and it is the skills to work in that relationship
we need to work on. There are also technical skills as well. Sex
is a technical skill—whether it is about how to use a condom
or whether it is about negotiating a relationship. I think sometimes
those things are forgotten about. We need to be thinking about
what the skills are and what the resources are. People might know
they need to use a condom but they might not know where to get
one or they might not be able to afford to buy one, etcetera,
etcetera. For me it is information but it is also about skills
and it is also about resources and it is also about supporting
people to make those choices.
423. You have already mentioned targets under
the sexual health strategy with the teenage pregnancy target and
you said in GUM because there was no target that is a disadvantage;
is that right?
(Mr Springham) There are targets around HIV prevention
that could tie into GU services, but those are not mentioned in
the list of key targets that have come out in terms of PCTs' local
delivery plans. To achieve the teenage pregnancy target is there
but there is nothing specifically around GU targets. Obviously
there are the targets that exist in the national strategy and
we need to be meeting those as well. My worry is if the headline
target is teenage pregnancy maybe GU will once again be a poor
relation.
Mr Burns
424. Again if I could ask Ms Asanti-Mensah and
Mr Springham; do you think the long-term targets set by the Government
to seek to halve the level of teenage pregnancies by 2010 and
to reduce new cases of HIV and gonorrhea by 25 per cent in 2007
are appropriate? Do you think that it would be helpful to see
health promotion services shored up by more specific and measurable
targets?
(Mr Springham) I think there are two different targets
to start with. One of the difficulties about a target that is
set around reducing levels of HIV is that if you are going to
improve service provision then inevitably you may well uncover
more cases of HIV infection, so as your services get better then
the number of HIV cases that you find goes up as well because
you are making those services more accessible, more people are
coming through, more people are being tested. Around teenage pregnancy
it is a very tough target, especially where I come from. Our target
is not to reduce by 50 per cent, it is to reduce by 55 per cent.
In order to reach 50 per cent across the country different areas
have different amounts they need to work to. I think targets are
important because they do give us something to push towards and
strive towards. I know certainly within the primary care trust
that I work in the fact that people are starting to say, "Are
we going to meet these teenage pregnancy targets?" is making
people sit up and say, "Maybe we need to invest in extra
resources, maybe we need to be doing something different in order
to meet those targets." So I think targets are useful, but
we also need to bear in mind if they are hit and miss at the end
of the road that would be a very sad thing because there are all
sorts of things we need to do on the road to meet the targets
otherwise we are just going to get to the end and say, "We
didn't make that, did we?" Maybe it was useful in looking
at targets also to look at some of the milestones along the way
to show that we are moving towards that target. What was the second
part of the question?
425. Would it be helpful to see health promotion
services shored up by more specific and measurable targets?
(Mr Springham) Targets in health promotion are sometimes
difficult. You might come up with a target that in ten years'
time—because they are long-term targets—we will have
reached this reduction in teenage pregnancy, or whatever it is.
The difficulty about those kinds of targets is that PCTs quite
often still see them in terms of what are we doing clinically
to achieve those targets rather than do we need health promotion
targets. I am not sure they have been looked at but I think they
might be help.
(Ms Asante-Mensah) To support what Nick was saying,
in terms of health promotion it is very difficult to have measurable
targets around health promotion because a lot of the work we are
doing is about supporting communities to develop skills and behaviour
changes. We really do see targets as very clinical, we want something
concrete at the end of it, and health promotion is not always
like that. A lot of our experience, particularly working with
marginalised communities, black and ethnic minority communities,
is around how to develop the skills to access services and sometimes
that is not always measurable. In terms of targets they are only
as good as the monitoring and surveillance information you have
got available. GU services are open access, people can go and
give whatever name and address they want, so from the information
we collect we cannot look at how we are doing because they are
not linked to districts of residence. We also need to look at
how strategic health authorities work with primary care trusts,
and to look at how we develop local targets that we can actually
meet and that mean something to us. As Nick was saying, if we
are going to be developing services and encouraging people to
use those and encouraging people to get tested, maybe the chances
are that the targets will not go down, they will go up because
more people will find that they can access services. We need to
look at how we measure success. I am not entirely convinced that
targets are the way to measure success.
(Mrs Abbott) As a teacher I support what they are
saying. We have to train the people before we can go anyway to
meeting those targets. In schools we have to train the staff to
support your view. It is all very well to push it with the media
but you have got to get through the fact it is the relationships,
it is caring, it is the promotion of values that means an awful
lot and goes an awful long way. You can set the targets, all very
well and good, but you have got to start with the training, you
have got to start with the support, you have got to start with
the nurses coming into the schools, you have got to start with
the teachers, and then you have got to get it through to the children
with the support of the health authority. Maybe they are a bit
ambitious but if you are getting the grass-roots right gradually
you may see things change.
John Austin
426. We will come on later to the mechanics
and delivering the programme to schools. Thank you very much.
(Ms Wellings) Can I make one last point on the targets.
We interview teenage pregnancy co-ordinators as part of the evaluation
of the teenage pregnancy strategy and they welcome targets to
give them leverage at local level to get things done. They can
point to successes and failures and galvanise efforts in an effort
to reach the targets. They are doing quite well. For ten quarters
the figures for teenage conceptions have been going down, and
they are measurable because everybody registers a birth.
Jim Dowd
427. If I could follow up the second part of
Mr Burn's question on health promotion services. Clearly this
question again is to our two PCT representatives. What role do
you think there is for GPs as level 1 providers in primary care
in the health promotion and preventative services? If the answer
is anything other than none, how well-equipped do you think they
are to meet that?
(Mr Springham) I think clearly everybody who works
in primary care does have a role around primary prevention and
health promotion. I think one of the difficulties is about what
that role is with regard to sexual health promotion because sex
is not a clinical issue, it is a social issue. I am not sure that
the clinic is the best place to be promoting sexual health in
the most effective way, I think the community is. That is where
people are sexual, that is where they have their relationships,
etc. I think it is important that the messages are clearly given
through primary care. As far as I know there is clear research
that shows if your GP tells you that you really need to do something
you will think about it seriously. You might not act on it but
you will think about it seriously. I think those messages need
to be backed up in primary care but actually the majority of work
needs to take place out in the community, whether that is within
a school setting or in youth settings, in the pub or the club,
etc., etc., because those are the sexual arenas, if you like,
rather than your GP's surgery.
(Ms Asante-Mensah) We need to look at the practice
team and whether the GP is actually the most appropriate person
within that practice team to deliver prevention messages. I think
it will also vary with the interests of the GPs as to whether
or not this is what they want to do. What we need to do is to
look at how we support and train the practice team in delivering
promotion and prevention messages. Our experience in Manchester
and Central Manchester is we have an initiative called COMET—I
cannot remember what it stands for—which is about training,
whole systems training for primary care. It is about rethinking
how we use that time if we want to educate and support the development
of GPs' skills and their practice teams. We need to look at it
as practice teams as opposed to "it is the GP's role"
because I am not sure that people who go to their GP want their
GP to give them the messages and sometimes relationships are a
lot better with the practice nurse and they may be better placed
in terms of the caring and supporting aspects. I am not saying
for a minute that GPs are not caring and supporting but it is
about how much time and the skills that there are and who you
choose to go to. I think it should be looked at on a practice
basis as opposed to just the GP. They will need training and support
to enable them to get the messages across.
428. When you say "support" does that
mean resources, more money?
(Ms Asante-Mensah) Not necessarily. I think it is
about training and information. I suppose financial resources
will always be an issue. If we are looking at using some of our
COMET sessions around sexual health promotion and HIV prevention
we are not going to be able to do other things. It is not always
about money, it is about how we support clinicians, practice nurses,
practice teams, and how you develop multi-disciplinary practice
teams to deliver this agenda.
429. Okay. There are specific groups of the
population that everybody agrees we need to have a particularly
targeted message towards because of their particular exposure
to STDs and related issues. How do we reach these? What are the
targeted messages?
(Ms Asante-Mensah) Our experience, putting my voluntary
sector hat on, is the Black Health Agency works with a whole range
of minority ethnic communities: African, Caribbean, South East
Asian in the main. We have had to look at different ways of working
with those communities. I think there are different issues within
those communities and we cannot have a blanket approach to them.
We have used things like peer education within the schools with
particularly Caribbean young people around sexual health and HIV.
That has been very much about supporting and developing and enabling
them to acquire the skills so that they can negotiate and also
to develop messages that they can pass on to their peers who will
take on those messages probably much better than if I were lecturing
them. We are also working with community groups because I think
it is about how do we support and enable communities to do it
themselves, to recognise where they are at and what issues they
are coming with and working within that. As opposed to going in
and starting to work around sexual health and HIV, our experience
has been that people are quite happy to remove themselves from
HIV particularly but if we work with them around other issues
and introduce sexual health and HIV they are more likely to take
on those messages. It is a long process and sustainability is
really important. It is about supporting and developing skills,
knowledge and awareness but at the same time we need to work with
service providers so that when we are promoting services and telling
people to go and get tested that when they go the providers are
able to deal with them in a supportive and sympathetic way and
from a knowledge base. Part of the difficulty is within Central
Manchester we have got a wonderful vibrant diversity but that
brings its own issues. We have also got refugees and asylum seekers
for whom we might think sexual health is an issue for them but
they might not. It is about how we work within their community
networks to ensure we are engaging them from where they are at
and starting from that point as opposed to going in and telling
them this is the information that they need.
(Mr Springham) I agree with everything that Evelyn
has said. It is also important particularly around HIV, gay and
bisexual men, particularly young gay and bisexual men, we need
to be targeting work around that area. Unfortunately we are still
in a position, and maybe we can talk about it later, where in
terms of sex education in schools and in youth services, etc.,
young gay men are still not receiving appropriate information
around sex education that they may need to protect themselves
in terms of sexual health. We know that levels of HIV are beginning
to increase again amongst gay and bisexual men, so that is important.
We still have some work that people feel worried about doing because
we still have section 28 on the statute book which says that somehow
you should not do certain types of work that might promote homosexuality.
That is a problem in some cases. It is also important that we
look at those other traditionally disadvantaged groups, for example
young disabled people or disabled people in general, deaf people,
refugees, as has been mentioned. In any of those groups within
the community where we feel there are health inequalities you
will also find that there are sexual health inequalities and we
need to be targeting work at those groups.
430. Is it uniform across the whole range of
health provision, is that what you are saying, that those who
suffer disadvantage in any particular field in health always have
the same profile? Surely that is not right.
(Mr Springham) Is it always the same profile? I think
there is some kind of correlation that if people are disadvantaged
and do not have access to good service provision or good education
or good resources, whether that is about whether they can access
healthy food or whether that is about whether they can access
condoms and information that promotes sexual health, there may
well be a correlation.
John Austin
431. Would you include sex workers as a particular
group to be targeted for health promotion?
(Mr Springham) Clearly.
(Ms Asante-Mensah) There are particular issues for
sex workers. For sex workers it is also about giving them assertiveness
skills and supporting and providing them with accessible services
that are non-judgmental.
432. Professor Kelly, could I welcome you to
the other side of the table.
(Professor Kelly) Thank you very much. I was going
to answer Mr Dowd's question directly about the evidence on inequalities.
The unequivocal answer to your question is yes, that the inequalities
in health repeat themselves as inequalities in sexual health.
In the three areas we are concerned with here, namely teenage
pregnancy, STIs and HIV, we see patterns of disadvantage which
reflect more general patterns of disadvantage in the population
in the same way that we see general health inequalities bearing
in mind that it simply is not a matter of social class differences
we are talking about but all the other differences and variations
in the population by difference that we are focusing on here which
relate to gender, to disability, to ethnicity and indeed to geography
and all of these things repeat themselves in that pattern. For
example, the risk relating to teen pregnancy is ten times higher
among girls in social class five than in social class one. The
epidemiology clearly demonstrates that pattern of inequality,
so I think the answer is an unequivocal yes.
Mr Burns
433. The voluntary sector has played a very
important role in providing HIV prevention and social care services.
Do you think that there is a risk that pressure on budgets is
going to lead to a dis-investment in the level of service and
care that has been provided so far by the voluntary sector?
(Ms Asante-Mensah) I think it could. It relates back
to the previous answer about areas where there is a low prevalence.
Our experience in Manchester is that we have quite a strong voluntary
sector that may be fragmented at the moment but we are looking
at how we can become much more unified and provide services in
a much more effective way. There has been a recognition that the
voluntary sector can target those sectors of our population who
are hard to reach who may not want to use mainstream services.
An example is refugee communities, asylum seekers, whether they
are legal or illegal, who may not want to access statutory services
because they do not know where the information is going. Our experience
is that people feel if they go and give their details it goes
to the Immigration Service.
434. Sorry, why is there a problem if they are
legal refugees?
(Ms Asante-Mensah) I think it is about access to services
and people not knowing what happens to their information and who
has their information and what they do with the information that
is collected. Whether you are applying for asylum or refugee status
legally or you have come into the country illegally, a lot of
the pressures and issues are fairly similar in our experience.
I think the voluntary sector can and does and has provided services
in a way that sometimes statutory services cannot do. The difficulty
in areas where there is low prevalence is anecdotal evidence and
discussions we have had within the North West and Greater Manchester
have shown that there are areas where PCTs are not commissioning
with services that the health authority used to commission because
they do not see HIV particularly as an issue because it is a very
low prevalence. It is about ensuring that where numbers may seem
invisible, they may be low numbers, those services are shored
up. PCTs are working within a very difficult financial environment
at the moment and it is not the case that they may want to but
it is about reaching a financial balance in any way that they
can. Sometimes the easiest way is to trim off the edges and quite
often we have not seen the voluntary sector as part of mainstream
provision which actually we should be doing. If we were looking
at the voluntary sector as part of the mainstream then we would
not see them as the periphery. Until we start seeing them as part
of the mainstream then I think that there is a very real danger
that the resources can be diverted from them into other mainstream
provision.
(Mr Blake) Can I just make one more point about the
voluntary sector. Increasingly budgets are being cut for the core
costs of the voluntary sector and a huge amount is delivered through
the voluntary sector on very small amounts of money anyway. There
is a huge amount of work which goes on within the voluntary sector
which is unnoticed and unpaid for around a certain provision.
I know that it is a real issue in actually helping to deliver
direct services, because often those have been cut, but also in
doing the planning, preparatory work, being at the right table
at the right time to get the issues on the agenda which are the
real issues in terms of the funding of the voluntary sector.
John Austin
435. Can I just follow through what Simon Burns
said. Leaving aside the question of whether people are legal or
not, would you say there is a particular problem for people who
may be legal but are awaiting determination of their application
in receiving or accessing services?
(Ms Asante-Mensah) I think there is an issue in people
coming forward and services not knowing what the legal status
and the rights are of people who are applying for refugee status,
whether that be legal or illegal. There is a lot of education
and training that needs to happen for service providers in terms
of what the legal rights of people are.
Dr Naysmith
436. I would like to ask Professor Kelly a couple
of questions about the Health Development Agency's role in all
of this and can I start by two quotations from the documentation
we have seen from the Health Development Agency. First of all,
it says the Government's strategy "seems to place a greater
emphasis on the absence of disease than on the promotion of well-being"
and then "more attention needs to be paid to the role of
sexual health promotion." Is that a fair summary of what
you are saying? Can you expand a little bit on this? What do you
believe should be done to achieve this emphasis on sexual health
rather than absence of disease?
(Professor Kelly) I suppose contemporary thinking
on public health matters recognises that if we are to improve
public health we need to work on three fronts simultaneously.
One is about appropriate medical care and health services; one
is about individual lifestyles and behaviour; and a third is about
what is often called the "wider determinants of health",
the socio-economic environment in which people work. Our comment
in that document was really to acknowledge absolutely the importance
of the absence of disease, the reduction of disease and not for
one moment to suggest that that is not a significant and important
aspiration, but at the same time we should not forget that those
other factors, the wider determinants and social behaviour, are
equally critical. The problem may arise in that if there is an
over-exclusive attention on targets which are entirely clinically
based these broader issues might be overlooked. I have mentioned
already the question of teenage pregnancy, but it seems to us
reviewing the evidence that teenage pregnancy and the particular
prevalence of teenage pregnancy across the population, is as much
a problem of poverty pre-conception and disadvantage as it is
about appropriate services. It is then about delivering those
appropriate services where they are most needed and providing
appropriately tailored programmes to them. If you focus exclusively
on the end product, the outcome, and ignore the broader determinants
within which these things are taking place, there is a danger
of imbalance, and it was to try and bring that back into focus
that I think was in our minds.
437. The interesting thing about these broader
aspects is that people differ much more on what you should do
about them rather than they do about making sure infection is
controlled and that sort of thing. It gets you into an area where
it is much more difficult to agree targets and get people to do
things.
(Professor Kelly) It is more difficult, as you have
said, because the causal pathways from the broader determinants
to individual outcomes are much more difficult to define and to
research. It is much more difficult because the levers of policy
are quite different to those about changing accessibility to services
and they are much more difficult because they tend to be broader
and longer term and the outcomes are therefore more difficult
to see in the political time horizons that we tend to work to.
Nonetheless, we would be ill-advised not to focus on those sorts
of things. That said, to go back to an earlier question about
targets, while the clinical targets are important there are other
broader targets reflecting the work of local authorities, reflecting
what is happening in schools, and reflecting what is happening
in the national curriculum, and all those sorts of things that
can be turned into targets which reflect these broader issues
and can be inter-woven, so it is not a forlorn task to look at
the broader determinants at all; it is a task that can be brought
under control if we keep a broader perspective.
438. The HDA is identified within the Strategy
and Action Plan as undertaking a review of the evidence base for
HIV, sexually transmitted infections, and teenage pregnancy prevention.
Presumably that is being undertaken to inform best practice. What
is the HDA approach to this and what are the main recommendations
to date? Are there any messages you can give us so far? I know
it is work in progress.
(Professor Kelly) It is work in progress but the first
tranche of the work is complete. For the last couple of years
we have been reviewing world literature on those topic areas—along
with another 14 or 15 areas of public health—and we are
either bringing to publication or have just published or will
be publishing in the next several months reviews and syntheses
of these world literatures and what they have to say. It is an
approach which requires us to look at the very best systematic
review data, meta-analysis and that sort of thing, to try and
weave this into a synthesis so we can produce top-level findings.
We are going on in our subsequent programme of work to look at
other types of evidence from other sorts of methodologies, qualitative
methodologies and so on. I am summarising the equivalent of about
eight years' work in these three areas. First of all, with respect
to HIV, what we know, what the evidence tells us is that effective
interventions are those which are placed within the context of
the people to whom they are directed, their knowledge, their skills,
their community norms, their values and that sort of thing. In
other words, they have to be highly targeted and very specific
to the groups to which we are talking. Secondly, they have to
be tailored therefore to those populations. Thirdly, those which
are multi-component relate to information and the skills we heard
about earlier on—negotiation, practical issues and those
sorts of things, which tend to work much better. We heard a moment
ago about commercial sex workers. We know with that group one
of the consistent findings we have is that peer-led community-level
education is effective there. When we go on to looking at sexually
transmitted infections, I suppose there are four or five things
I would want to say. Those which are based on clearly-defined
models of behaviour change work best, in other words, if there
is an underlying psychological or social-psychological kind of
approach. Secondly, those that provide basic, accurate information
about the risks of unprotected intercourse and how to avoid that
work well. Again, it must be multi-component and include different
levels of things like skills and so on and so forth which are
based on what we know about the beliefs and attitudes of the target
populations that we are talking to. But last it needs to be in
appropriate time. One-off things do not work very well. We are
talking about people's development, say, through early childhood
and into adolescence, and for some audiences peer education works
well.
439. Could I stop you there before you go on
to teenage pregnancy. Are any of the things we are doing now really
a waste of time that we should not carry on with and resources
should be moved elsewhere?
(Professor Kelly) Not in a blanket sense, no, but
what you would want to do is look specifically at the target population
and ask the questions does it work for them, under what circumstances
does it work for them, and what sorts of outcomes can we expect
to see for them? It is a question of horses for courses really.
If we start from the premise that there is a single type of sex
education or a single type of approach to working with HIV, or
indeed with teen pregnancy, that will cover the whole of the population
forever and for always, this is not going to work, it is not like
that. In a way it goes back to what I was saying about the broader
determinants. The social variation in our population is actually
much greater than its biological variation. What we fail frequently
to recognise is precisely that point and we try and apply it as
if we were giving an aspirin and as if it would work in certain
biological parameters. We have got what is a much broader spectrum
of the population and what we have not been very good at—this
is in public health as a whole not just with respect to the issue
with which this Committee is concerned now—is to get a real
good sense of the variegation of the communities whom we serve.
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