Examination of Witnesses (Questions 520-539)
THURSDAY 28 NOVEMBER 2002
DR GEORGE
KINGHORN, DR
PAT MUNDAY,
DR CHRIS
FORD, MS
MARIAN NICHOLSON,
MR GRAHAM
TAYLOR AND
MS JACKIE
ROGERS
520. And, as far as you know, does the government
accept or reject, for example, the figure of 180 to meet the EU
directive?
(Dr Kinghorn) I do not know. Certainly I have not
heard any criticism of the figures and I know that it has been
accepted that there needs to be an increase in the number of trainees.
I presume that by that acceptance the size of the consultant requirement
has also been accepted.
521. You do not know to how many?
(Dr Kinghorn) I do not.
522. And also, within the Royal College of Physicians,
is there any attempt to try and get agreement across the specialties
that there is parity between the two different things? It is very
obvious to us the huge pressure that you are under, but then we
can see there may be an argument within the Department of Health
when there are other specialties that are saying, "Our disparity
is even greater". Is there any agreement to ensure there
is parity?
(Dr Kinghorn) Within the College Committee we are
very much alive to the problems and the needs of what is called
modernisation—the needs to make better use of all of our
staff. There is firm support for the strategy within the College
Committee; there is no doubt about that.
523. I did not mean within GUM—I meant
within the Royal College of Physicians and whether neurologists
and GUM try and have an agreement about this parity—that
one per 113,000 GUM is parity and one per X is neurology. Is that
done?
(Dr Kinghorn) Yes.
John Austin
524. Can I go on to the delay in accessing services?
We went to Manchester, and it was my thought that Manchester is
a special case because of the high pressure there but the evidence
we have had from London, Sheffield, Wales—all over—suggests
a similar problem in accessing services, and the Public Health
Laboratory clearly says that delay in accessing those services
increases the duration of infectiousness and the probability of
disease transmission. Could you, Dr Kinghorn, tell us what effect
you think the increase of patient numbers has had on patients'
ability to access certain clinics, and what significance that
has had in the rise of STIs and HIV infection?
(Dr Kinghorn) Can I just put this problem in perspective.
We have been so concerned that we have been doing regular surveys
of clinics to find out how long it is before they can see the
so-called routine patient. We know that the median time in clinics
in England now is 14 days and rising. To put that into some sort
of context, the number of clinics who are able to see patients
within a week is about 20 per cent; within two weeks, 50 per cent;
and over a third are unable to see patients for three weeks or
more. It is inevitable that delays in access tend to adversely
affect those who are in greatest need, particularly young people,
those from ethnic minorities, and those from deprived backgrounds.
With young people there is a window of opportunity, and that is
now. It is the day and the time that they present. In my view
they should never be turned away, but that is happening. We know
that some clinics, such as Archway in London, do not book appointments
until 10 am one day beforehand and they have about 50 appointments
for the following day. By 10.15 all of the male appointments are
taken up and it takes about seven and a half minutes to fill up
all of the appointments for the female patients. The demand, and
the number of patients who are turned away and advised to go elsewhere,
is three times the number of people that can be accommodated.
That is potentially a disastrous state of affairs because some
people will never come back. The longer that an individual has
an infection for the more likely they are to transmit it to others.
Not only are they more likely to acquire the complications of
sexually transmitted infections, which may be very serious for
that individual for the future, and may also be very costly. I
think the issue which should concern us all is that the presence
of sexually transmitted infections is a major factor in the acquisition
and the transmission of HIV. The increased numbers of HIV that
we are seeing at least in part are related to on-going and probably
increasing transmission. We are therefore running into the dual
problems of increased STI morbidity for the individual patient
as well as increasing amounts of very expensive HIV.
525. The Royal College of Physicians suggested
that people should be seen on the day they present or the next
occasion the clinic is open. Clearly that is not what you have
described. Do you think that access targets should be set?
(Dr Kinghorn) Yes. The College of Physicians' recommendation
was something that was contained within the Monks' Report in around
1990 and that was supported by ministerial letter. This was, as
far as we were concerned, a directive: it was not something which
was optional. It was a directive to us that we should view all
our patients as required urgent attention. Physicians working
within the GUM service believe that still to be true, and many
of us are seriously concerned about our inadequate access at this
present time. I would always argue for the highest standard and
I would not like to see this standard diluted in any way. General
practitioners will be recommending that all patients should be
seen within 48 hours. Surely for a communicable disease the standard
should be no less than that.
526. Since money is a major determinant of decisions
in most public services, you have indicated that delayed access
in services not only increases the likelihood of transmission
but you also said that it can lead to more serious consequences
for the patient, more costly outcomes, more complicated consequences.
Is there any way in which the additional costs of delay could
be quantified in order to justify or better make the case for
more resources in the first place?
(Dr Kinghorn) Last year there were 4,500 new cases
of HIV. Each of those patients costs £12,500-15,000 of treatment
care costs per year, therefore the additional cost of HIV last
year to the country will be at least £56 million. It will
be even more for newly diagnosed cases in 2002. The costs of implementing
the national sexual health and HIV strategy in full will be far
less than the costs of HIV. I know that we are here particularly
to talk about STI treatment and care today. In my department 1
per cent of my population is HIV infected. They take up more than
two thirds of all of the resource within the department. I see
12,000 other patients whose cost of a completed treatment episode
for GU medicine is about £150 compared with £12,500-15,000
for each HIV case. It must be cheaper to do the job properly.
Sandra Gidley
527. For the sake of clarity could I pick up
on this: you describe the routine patient. Could you define a
routine patient?
(Dr Kinghorn) They are often self-defined. Many clinics
will have a triage system so those who are most articulate will
be able to negotiate their way round that system and will be able
to be seen more quickly. Those who are less articulate, those
for whom English is not their first language and those who are
young, are likely to have longer delays. A routine patient, in
answer to your question, is simply one who rings up who wishes
to be seen. If we try and prioritise those patients, that requires
an interaction with a health care professional to make an assessment
as to the degree of urgency with which they should be seen.
528. Let us move on slightly to the smaller
and part-time clinics. Are there any particular problems associated
with the smaller units rather than the larger ones, and maybe
Dr Munday or Jackie Rogers would like to answer this.
(Dr Munday) Thank you. Small clinics are usually run
by a single-handed consultant with one or two or three nurses
and perhaps a health adviser, and open one or two, or maybe three,
four or five days during the week. When that consultant is there,
the service runs. When the consultant is not there, the service
closes. So that in order for the service to run, one has to take
into account the need for annual leave, for study leave, for maintaining
clinical governance requirements and for negotiation, so all those
impact on a consultant's time and reduce the time available for
clinical care.
529. Can I ask a very silly question? Does the
consultant have to be there in order for the clinic to run? Can
a more junior doctor not run it?
(Dr Munday) There are no junior doctors.
530. So it is a single-handed practitioner?
(Dr Munday) Yes. Single handed consultants do not
have junior doctors, and most clinics in the UK are run by consultants
and non consultant career grade doctors without any junior doctors
around. That is the model of care. In my department, for example,
I am a single-handed consultant with several non consultant career
grade doctors who are part time and who work with me, and I have
a part-time junior doctor and that is it, and I see 17,000 patients
a year. You will see that is a lot more than Dr Kinghorn sees
in his clinic with four consultants and all the junior doctors
and all the staff he has. So it is an enormous workload.
531. What happens when you go on holiday?
(Dr Munday) My non consultant career grade doctors
cover for me, and in fact that is not really recommended by the
College of Physicians but we have no option. That is how it has
to work, otherwise the service would close. They are running the
clinic now as I talk to you.
Dr Naysmith
532. Are you saying that there has to be a consultant
on the premises?
(Dr Munday) There has to be a doctor on the premises.
533. So these junior doctors who do work for
you, although you said you were single-handed, can operate the
system when you are not there?
(Dr Munday) They can but they really need to have
access to a consultant if they have difficult cases.
534. Sure, but a fair amount of the work must
be fairly routine?
(Dr Munday) Yes. I think it is fair to say that my
clinic is quite a large single-handed clinic as compared with
many others. There are many clinics which have a consultant and
maybe just one or two GP clinical assistants doing a couple of
sessions and that is it, there really are no other people around,
so during most of the time the consultant is seeing all the patients,
him or herself[1]
Dr Taylor
535. You have highlighted the problem of the
single-handed consultant which goes right across all specialties.
(Dr Munday) Absolutely.
536. The only answer, and it is being found
in other specialties, is much more networking and you have absolutely
pointed to the difference between the service you are able to
provide and the service Dr Kinghorn is able to provide. There
has to be networking. Have you looked at that? Is that geographically
possible?
(Dr Munday) Yes, I think it is possible, but we need
funding for the new posts.
537. I realise the tremendous under-funding
of the whole service but in the short term, before the money is
necessarily there, could you share existing services to improve
yours without running Dr Kinghorn's down so much?
(Dr Munday) I think that the big teaching hospitals
are absolutely overwhelmed anyway. They do not have any spare
resources to pass on to us.
(Dr Kinghorn) The concept of networking is key for
the future. Networks are important both within and across health
districts. Within my setting that is done by shared consultant
appointments. I am a great believer that you need high quality
doctors and it is best to share those across two locations rather
than to have them located within one setting. My argument would
be that I want there to be high quality services wherever people
live, and I do not want to be doing any more work than is necessary
because. If there is a service which is good in one place but
not necessarily good elsewhere, patients will move. They will
migrate—or at least a proportion will—and it is therefore
in everybody's best interests to ensure high quality throughout.
It is also essential from the point of view of clinical governance.
We need to avoid the isolation of singlehanded consultants, and
certainly our strategy for the future is that new consultant posts
will be shared across networks between district general hospitals
and teaching hospitals.
Sandra Gidley
538. Would Jackie Rogers like to comment on
the smaller clinic?
(Ms Rogers) Yes, because I am very much involved in
one. I think one of the big problems is the time constraint of
clinics because if you have a part time service then you can only
see patients within certain hours. It means you have a limited
number of patients you can see and we therefore have to use an
appointment system with some flexibility for emergencies, of course,
but it means you can only ever achieve a certain number of patients
within that time physically. It also means that, if you have a
part-time consultant you usually have sessional workers and they
come in just to work sessional hours, and if they are only there
for sessional hours then those are clinical hours and there is
no time for teaching, for meetings or clinical networks, and it
means it is difficult for patients to access a service out of
hours if they want to ring for advice, if other professionals—primary
care, for instance—want to call us or contact us for advice
there is nobody there—in my case I am, but most of the time
there are no other staff—and that is very limited, both
from the patients' point of view and from our other colleagues'
point of view, and it is frustrating within the service because
you do not have the time to meet and to train and to discuss and
to network. Everything has to be planned into that clinical time
because it is so precious.
539. So where are people directed when you are
not there?
(Ms Rogers) They are directed back to their GP; they
have to because that is the only other option and that is why
it is so important that we are giving the same messages and we
have the same standardisation of care, and that is where the strategy
is in the PC report. We do triage, as most clinics do, and sometimes
it is a matter of giving some advice that will help that patient
get to the next appointment. Very often it will be their own anxieties
that puts the pressure on the service and they can wait for an
appointment, but it is very frustrating for us professionals to
say, "You have to wait", because you never know. You
cannot tell over the telephone.
1 Note by Witness: As a point of clarification,
there are three main types of hospital doctors: consultants who
are fully trained, junior doctors who are doctors in training
and non-consultant career grade doctors. This latter group is
very heterogeneous from GPs who do one session in a GU clinic
per week, to very experienced doctors who have chosen for one
reason or another (often family commitments) not to follow a career
leading to a consultant post. Most small clinics have a consultant
and a few other clinical sessions held by local GPs. Most teaching
hospitals have several consultants with a number of junior doctors
and perhaps a few non-consultant sessions. In between these extremes
are moderate size services such as my own which is dependent on
experienced non-consultant career grade doctors. While these doctors
provide an excellent service, they rarely take on any management
role and always need to have access to a consultant to discuss
difficult cases. It is generally regarded as undesirable, for
clinical governance reasons, for a consultant to work single-handed
without another consultant in the same speciality to share the
work load and management responsibility. Back
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