Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 513-519)

THURSDAY 28 NOVEMBER 2002

DR GEORGE KINGHORN, DR PAT MUNDAY, DR CHRIS FORD, MS MARIAN NICHOLSON, MR GRAHAM TAYLOR AND MS JACKIE ROGERS

Chairman

  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 treatment?
  (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 young people.

  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 appointment—etc, 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 is helpful.
  (Dr Munday) I would agree entirely with Dr Kinghorn.

Julia Drown

  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, acceptable.


 
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