Examination of Witnesses (Questions 513-519)|
THURSDAY 28 NOVEMBER 2002
513. Colleagues, can I welcome you to this session
of the Committee and thank you very much for your co-operation
with our inquiry. Could I ask you briefly to introduce yourselves
to the Committee?
(Mr Taylor) I am the Brighton and Hove
City and the East Sussex PCT's primary care trust commissioning
manager for sexual health and HIV services (with apologies for
the long title).
(Ms Rogers) I am the lead nurse for sexual health
services, and I am the local lead for the two PCTs in our area.
(Dr Kinghorn) I am a GU physician from Sheffield.
(Dr Munday) I am a GU physician from a district general
hospital in Watford, west Hertfordshire.
(Dr Ford) I am a GP from Kilburn, north London, and
the chair of the Royal College of General Practitioners Sex, Drugs
and HIV Task Group.
(Ms Nicholson) I am director of the Herpes Viruses
Association which is a patient support group running since 1985.
514. Can we begin by asking you, Dr Kinghorn,
a question about the increases in workload? I think all of us
have been very concerned with the evidence that we have picked
up and you have been involved in this area for a long period of
time. Can you talk about the reasons you see for the increases
and the pressures that the service is under? Obviously we have
had evidence that suggests that if we use 1994 as a starting point
that is not necessarily giving a full picture because of certain
factors in the early 1990s. What would the picture look like if
we, say, went over 25 years, for example?
(Dr Kinghorn) I started 25 years ago, in 1976, in
Sheffield. The workload in 2001 in comparison had quadrupled,
but if we take it over a more recent period of time, if we look
at the number of diagnoses made in GUM clinics over the past ten
years, they have doubled. We now see something like one and a
third million new conditions in GUM clinics per year. In terms
of the new patients that we see, we saw 624,000 last year out
of a total of almost 1.5 million total attendances. But in addition
to the increase in numbers, there has also been an increase in
complexity because GU medicine is the major provider for HIV treatment
and care within the country. If we look since 1996, when we had
the start of an effective treatment for HIV, in my department
the annual numbers that we look after have trebled. Last year
there were 4,500 new diagnoses in the UK; I have no doubt that
the number of new diagnoses this year will increase because in
my department we have had almost a doubling of new cases this
year as compared with last. So we have had an increase in the
number of cases in terms of quantity but also in terms of complexity.
This contrasts with the dearth of new resources particularly since
1997. We have seen that consultant expansion has virtually ceased
over that period of time when we have had the greatest acceleration
in the number of new cases, so that our capacity to cope with
the patient workload has been well exceeded.
515. In the time of the 25 year period that
you have been working, you have talked about the workload quadrupling
in that period of time. Is it that we have got a similar increase
in the incidence of disease, or is it that people are now more
prepared to seek treatment and more aware of the need to seek
(Dr Kinghorn) I think it is a combination of the two.
GU medicine clinics over the course of time have become more recognised
for their expertise within this area; there is greater preparedness
of patients to present. Undoubtedly AIDS education within the
mid-1980s brought this to the fore. We also have to acknowledge,
as has been shown in the NATSAL studies, that huge changes that
have taken place in sexual behaviour particularly in the past
ten years. We know that the age of first intercourse is tending
to fall: we know that the number the average number of lifetime
sexual partners has increased, and it is almost inevitable under
those circumstances that the number of individuals who will acquire
a sexual transmitted infection will increase. I think the analogy
will be similar to the number of cars on the road. The more cars
there are on the road, it tends to be that there are more accidents!
516. I understand the point you are making!
We may get on to this in more detail but in looking at where we
go in relation to the strategy, these trends in sexual behaviour
are perhaps a difficult area for any government to address. We
learned, or some of us did, in Manchester about anonymous sex,
which was a term that one or two of my colleagues had not come
across before, but how do you see any government being able to
address these wider societal issues which clearly need to be addressed
in the context of looking at sexual health?
(Dr Kinghorn) I think that there always has to be
a combination of approaches. There needs to be good education
and good information, but that alone will never deal with the
problem; it must be backed up by effective services. We are about
to enter a time where there will be a national awareness campaign
which will make clear that the proportion of individuals below
the age of 25 who have a sexually transmitted infection may be
more than one in ten. We will be emphasising that such infections
will need to be detected by screening and that there is a necessity
to present for health care. The concern that we have is that it
is essential that we have the capacity to meet the needs of these
individuals who present for care with fears that they may have
acquired an infection. Our concern at this present time is that
although the strategy provides an excellent framework in order
to deal with these problems within the future, we do not have
the capacity at this stage to meet these needs, especially of
517. Do any of the other witnesses want to add
anything, because there are some fairly wide ranging questions?
(Mr Taylor) I would like, surprisingly enough, to
agree with my colleague. There is always a perception that commissioners
and providers of service may well wish not to agree on a number
of issues. The issue, as far as I see it, is quite clearly there
is a rise in STI transmission and quite clearly there is an issue
around the capacity of existing services to meet the existing
need. If we are looking at national media campaigns, then what
that means is awareness will be raised and people will want to
access a service but if they cannot do that as quickly as they
would like that means they will go back into the population and
may well never choose to access that service again because then
there is a perception that it is always going to be late, we are
going to have to wait 14 days for an appointmentetc, etc.
The issue for me and my clinical colleagues is always that I would
very much love to be able to commission additional services, but
the reality is that the time lag in the financial allocation process
means that the health authorities that were, and primary care
trusts that are, are always desperately trying to fund the combination
therapy costs and the drug costs and do not get ahead of it so
we can fund additional people to provide the service. I hope that
(Dr Munday) I would agree entirely with Dr Kinghorn.
518. I would like to ask about consultant numbers.
Many people have written to the Committee and have pointed to
the Royal College of Physicians' recommendation that there should
be one consultant per 113,000 population whereas at the moment
there is one per 400,000. The trouble is that in other specialties
the imbalance is even greater. How do you move forward from that
in terms of saying how many consultants really are needed, and
is there an issue that perhaps some of the work could be done
by other members of the clinical team?
(Dr Kinghorn) To answer the latter part first, there
is no doubt that we need to make the best use of all of the skills
of local multi-disciplinary teams and that is a process which
is already in evolution and happening. The latest manpower figures
which we have from the Royal College of Physicians' survey 2001
show that we have 247 consultants in England, which is 238 whole
time equivalents. Based on the number of excess notional half
days that doctors are performing at this present time and to meet
the EU directive working time, which causes me quite some concern,
the additional consultants required number 180. Based on the Royal
College of Physicians' recommendation, which has been revised
to 1 per 119,000, we would require an extra 173 for England.
519. On top?
(Dr Kinghorn) Yes. We at present have about 120 specialist
registrars who are in training and their training period is four
years, so our output of consultants potentially is around 30 per
year. So clearly it will take us some time. Even if the will and
the finance were available to meet our requirements during that
period of time, because I believe that the latent demand for GU
medicine services is so much greater than has been indicated so
far, it is clear that not only do we need to increase consultants
but we have to make better use of nurses and health advisers in
particular. We also need to be ensuring that our core services
can spread out into community settings. It is very important to
make sure that the services and the expertise can be nearer to
where patients live, to make it much more accessible and, I hope,