Examination of Witnesses (Questions 540-559)
THURSDAY 28 NOVEMBER 2002
DR GEORGE
KINGHORN, DR
PAT MUNDAY,
DR CHRIS
FORD, MS
MARIAN NICHOLSON,
MR GRAHAM
TAYLOR AND
MS JACKIE
ROGERS
540. No, quite. What happens in districts where
there are not any departments of GU medicine?
(Dr Kinghorn) It is often a black hole. What should
happen is that there would be an agreement between that district
and the adjacent one that they would provide the service. I would
like to be able to say that money would follow their patients—that
does not always happen—but clearly those groups who live
in those areas are going to be disadvantaged compared with people
next door. The demand is there but inequalities will be encouraged
by the absence of a service.
541. We had a local problem recently in as much
as at Basingstoke Hospital the managers I think decided they would
like to cut out the HIV/AIDS cover and that it would be fine for
people to travel to Southampton, which is quite a distance. Is
that a fairly common occurrence? It is not going to happen I am
glad to say, but how frequently does that situation arise?
(Dr Kinghorn) I think it is uncommon. It is a very
unusual and, indeed, bizarre decision and I am very glad to see
that it was reversed. People should be able to receive high quality
care in the place where they live and for communicable diseases
we cannot afford to delay. In answer to one of the questions earlier,
the difference between neurology and GU medicine is that my patients
have something they can transmit to someone else; that is why
it is important. There is a public health imperative. It is not
just a moral or a health matter for that individual: it is the
fact that potentially that problem can be transmitted to others
and the problem will multiply, so having accessible and high quality
services locally for the range of conditions is important. Certainly
expertise in some aspects of HIV care and in-patient care may
well be localised within a network. There needs to be good liaison
between the local provider, who is likely to provide most of the
out patient care, and the inpatient care centre. It should happen
by planning; not by default.
(Dr Munday) The idea of HIV services being conducted
only in large centres has indeed been floated—it was floated
in my particular trust about the time that antiretroviral therapy
became available, and the trust was looking at the potential costs
to their population. Fortunately they did not go down that path
but I do think that units such as mine on the periphery of London
are always going to be vulnerable to pressure from PCTs to reduce
the HIV workload by sending patients down on the train into London,
and particularly with the patients that we are seeing at the moment,
who are largely patients from ethnic minorities, their ability
to get a bus fare to come to our clinic let alone find their way
into central London is compromised by the current situation, and
I think they would be lost to the service if they were forced
to seek their care in central London.
Chairman
542. Can I pick up a point, Dr Kinghorn? You
are talking about this being a public health issue and certainly
some of the concern this Committee has had over a long period
of time has been the way in which we have perhaps lost some direction
on public health. What are your thoughts on the role of our public
health professionals in respect of sexual matters, particularly
as they are located within PCTs? Do they engage in this issue
at all? We picked up a crisis but I am not getting idea that public
health professionals are trumpeting about crisis in a way that,
were they aware of it, I would expect them to do.
(Dr Kinghorn) I think there is a degree of truth in
that. In many places the local control of sexually transmitted
infections has been a matter for the GUM physician. In an ideal
world, there would be at least three different individuals involved—the
GUM consultant, the local CCDC ( the local public health doctors)
and the microbiologist—then you can get a clear picture
of what is going on. Clearly primary care is essential and there
need to be good links there too. Because of the confidentiality
issues related to genitourinary medicine I think public health
doctors in the past have been less involved than they might have
been. Certainly we get very good support from CDSC, the Communicable
Diseases Surveillance Centre, in London but locally the support
often has been lacking—but that may be our fault. Maybe
it is our job, in fact, as clinicians to make sure our public
health doctors are aware of this situation, understand the public
health importance, and also are helping to champion the cause
of the people that we look after.
543. What worries me about this whole area is
how we can ensure that the kind of crisis—and I do not use
that term loosely—that sexual health is facing in the UK
is somehow brought into the main stream of political debate. One
of the problems we have is as MPs. I have been an MP for 16 years
and I do not recall ever having a letter from a constituent about
difficulty accessing a GUM clinic. It is not the sort of thing
that happens. Therefore, if MPs are not made aware of these difficulties,
how does the democratic process change what is a very serious
situation? I am looking at the mechanisms of the professionals
involved and why those mechanisms involving the public health
people are not clicking in to ensure that we have in the Department
of Health a response to what is a very serious and worrying situation
throughout the country?
(Ms Nicholson) Doctors are trying to do their best
with the limited resources. The people with the money have got
to give it to all their people and all the departments in the
National Health are all screaming for more money. In the case
of baby units and cancer and hip replacements, you have the patients
speaking up for their needs. In GUM, apart from a few HIV groups,
no one is prepared, as you said, to write to their MPs so it is
unique in that way. The shame of having a sexually transmitted
disease keeps the patient quiet and doctors, I am afraid, have
just got to take on the burden of speaking for them, and there
has to be an understanding from the people who can disburse the
money that in this case they have to listen to the doctors with
more awareness than they would in other specialties which do not
carry the same stigma.
(Mr Taylor) To an extent I would agree but clearly
there is also an issue about people not wanting to self-identify
anyway, for a whole range of reasons. It is not just about stigma
and shame; it is about attending the service once or twice and
then not again. It is not like you are going back for regular
outpatient appointments or sessions. Somebody asked me a little
while ago, "Do you consider yourself to be a user of the
GUM service?", and my answer was no which is interesting.
If I am saying "No" and I am the commissioning service
and I go along once a year for my regular MOT, then of course
the population itself will predominantly think, "Of course
not". It is not just about attitudes around embarrassment;
it is about not self-identifying because you do not go frequently
enough. The other issue around public health networks for me is
around the priority it is given by the government. I know it is
part of the reason why we are here today but, if you look at the
priorities set by the government, prior to shifting the balance
of power which identified the shift of primary care trusts, there
was a whole set of "must do's". "You must meet
this target"; "There is an NSF for this"; "You
will stand on your head and multiply by three"—a whole
set of things had to be done. After shifting the balance of power,
the responsibility then rested with PCTs so consequently anything
coming out post PCT development has changed the language. It is
about setting standards and local PCTs deciding what they want
to do. If you then present a PCT with something that was prior
shift of balance of power which is all around "You will do
this, this, this and this", then you have something else
coming out saying, "You might also want to think about these
things", and a PCT chief executive is asked to respond and
performance manage a whole set of criteria which do not necessarily
include much around sexual health and HIV, what are they going
to choose? I know—the same as everybody else: the things
they have to deliver. Consequently their focus will, to an extent,
be on what they have been told they must do. That is not a criticism
of chief executives but a reality of the structure we are currently
operating under. So we have that slight change of terminology
which in this situation may be quite, and is, unhelpful from my
point of view because it does not raise the profile. That is why
the public health networks may well not be coming to you and knocking
on your doors, or why individuals are not writing to you.
Dr Naysmith
544. I would just say that I have never had
any representations from patients about GU medicine, but I have
from professionals working in this area who complain to me about
the levels of service.
(Dr Ford) This is one of the fundamental problems
because patients are part of society and if society thinks that
sex is a dirty subject then patients get that feeling. One of
the slight problems with the strategy was that it was very much
pushing a medical model rather than, "Sex is fun, most of
us have it, it is a very positive experience", and that should
be pushed in terms of education around sex, how to have good sex,
and sexual health for all. If you look at every other European
country, sex is regarded as normal and is talked about in a healthy,
open way. Terminations in young people are much lower because
sex is something that is talked about—it is not under the
carpet. We were doing some training just recently with primary
health care staff and they are members of society, and a qualified
nurse said to me, "Does any anybody have sex outside heterosexual
relationships in marriage?", and this was a very genuine
question and she is just one in society, so changing our general
attitude to sex and sexual health is vitally important.
Andy Burnham
545. Are you saying that there is something
peculiar about the British culture or character that makes these
issues more problematic and complex than they need be compared
to Europe, where they do not have the same problem?
(Dr Ford) I think they address it in a different way
and certainly it is talked about. There are similarities in terms
of drugs and the way drugs have been talked about—people
are given education and should be able to make a choice. The number
of young people I see who have never heard of chlamydia and who
go to wherever and get contraception; they get the contraceptive
pill but no information is given to them on how to stay sexually
healthy and what problems they might get into.
546. Would you not see the same scenario in
a very Catholic country where that same openness is not there
within the schools? Does that not show up in the statistics in
the same way?
(Dr Ford) Did you say in Ireland?
547. In any Catholic country?
(Dr Ford) I have not got that information. I presume
that it probably is a similar situation. If good sexual health
information is under the carpet, if it is not out there, then
it is potentially dangerous.
548. Equally you might argue that, because it
is out there, it has led to the trends in the NATSAL survey—that
people are having more sex earlier, younger, and picking up more
sexually transmitted infections?
(Dr Ford) If you look at Holland, for example, sexual
information is given to children much younger than in this country,
and sexually transmitted infections are lower and terminations
are lower because good information is given so people can make
a choice.
549. We have a situation in this country where
we have made more information available in the last twenty years
and there is now more sexual activity at a younger age, so there
is a correlation, is there not?
(Dr Ford) Where is the sexual information being given?
550. I think there is more sex education in
schools, is there not? There is more access to contraception?
There is more openness than there was, surely, twenty years ago?
(Dr Ford) I think you have to look at the quality
of what is being provided down on the ground in schools. Certainly
the sexual education that my kids got was slightly questionable.
Chairman
551. Did you say "questionable"?
(Dr Ford) Questionable, yes. "Don't do it",
sort of thing, which did not give them the choice!
(Dr Kinghorn) I do not think the correlation is necessarily
between the sexual behaviour that is promoting STIs and the amount
of sex education. The fact is that there is an imbalance between
the promotion of sex within the media and within society and that
is what has led to the increase in sexually transmitted infections
and the imbalance has been too little, or inadequate, sex education.
Many of us would dispute the suggestion that it is the increase
in education that has led to the change in behaviour.
(Dr Ford) I agree.
Chairman: Interestingly, your comments were
echoed very much by a group of young people in Manchester. They
made exactly the same point.
Dr Taylor
552. On public health, more and more directors
of public health in PCTs are not medically qualified. Is that
good or bad from the point of view of your subject?
(Dr Kinghorn) I will answer that from the point of
view of a doctor, and I think it is not necessary that they should
be doctors but I think that they need to have a good understanding
of public health issues, and particularly those that relate to
communicable diseases. We are at an unfortunate time whereby commissioning
has changed. We are in this process of change, and to a certain
extent we have inexperienced commissioners. Indeed, many of us
are finding it difficult to find who is our lead PCT for sexual
health, and even asking the department for such a list has not
yet produced it. Many commissioners are saying only "government
priorities" and NSF obligations will be funded by PCTs. Sexual
health, STI treatment and care—even HIV—are not priorities.
The typical response we hear is that there are no significant
targets for sexual health. These are the responses that my colleagues
are receiving from their commissioners at this present time. A
good director of public health does not need to be a doctor as
long as they have the insight and good communication.
Mr Amess: I find what Dr Kinghorn had to say
fascinating because I wholeheartedly agree in terms of the treatment
of sex by the media. You only have to turn the TV on and everyone
is at it, so is it any wonder—
Chairman: It depends which channel you
watch!
Mr Amess
553. It is everywhere. It used to be on Channel
4 and 5; now it is on the BBC—everything. The whole thing
has been trivialised. But just to outbid our Chairman, I am now
in my 20th year, and I have not had one letter on the issues that
you are talking about. I have had letters on fertility, people
wanting sex change operations and transvestites but your lobby
clearly is not being heard, so for us members of Parliament it
is new that we are in such dire straits. I do not know who is
responsible for organising your lobby but you need to get a handle
on them and get more engaged in this. Turning to Jackie Rogers,
we all know how difficult it is to recruit and retain nurses and
I would just be very interested to hear from you as to what you
think nurses are being used for in terms of delivery of sexual
health services—whether you think they are under-utilised,
or just what your opinion is generally. I think I know actually.
(Ms Rogers) I think you do! It is very variable, as
I am sure you have heard across the country. In some areas nurses
are still just chaperoning, doing very basic tasks and taking
out specimens, and in other clinics they are delivering a much
more holistic service; they are running nurse-led clinics and
that would involve sexual history taking, assessment of the patient,
examining them, doing the microscopy, and then giving treatment
and advice using patient group directions, so it is a much fuller
role. If you bear in mind the fact that there are more nurses
employed in delivering sexual health services than doctors or
health advisers, they clearly have a very important role and potentially
for the future they can make or break the sexual health strategy,
so I think we do need to look much more imaginatively at how they
can be used, and I think that most nurses would say that the senior
nurses within departments should be involved very much more in
designing and planning the models of care that are delivered and
looking at things like accessing and timetabling—that sort
of thing. So nurses could be and want to be much more involved
than they are in lots of cases, but they are restricted by the
traditional model in too many still.
Mr Amess: Dr Taylor when he was a consultant
did not jealously guard treatment services—
Julia Drown: I am not so sure about that!
Mr Amess
554.—in terms of nurses but obviously
there is an underlying tension there in that the government wants
nurses to do more. Is there a great variation in your experience
in the way clinics are used in terms of what the nurses do and
how they react with the consultant who is there?
(Ms Rogers) Yes.
555. It depends on the personalities really?
(Ms Rogers) It depends very much on the personalities,
but they are multidisciplinary teams—that is the way GU
medicine has always been—because we only have the patients
who maybe will only access that service once so we have to get
it right. We are very special in that way in that we work as a
team and that team approach is really important, and the nurses
usually want to be very much part of that.
556. I think Dr Kinghorn is itching to say something.
(Dr Kinghorn) Yes, I am. As I was saying before, we
were doing regular access surveys and we have done two this year
because we are so concerned. What we found in the second survey
that we have just done is that the number of nurse practitioner
sessions which Jackie has been referring to has increased by 30
per cent over this past year. I am very aware of the importance
of the impact of developing the nursing role—it is extremely
important in my department—and the way we are going to spread
good practice is via networks. Good practice in one place with
linked consultant posts and nursing and health adviser posts will
allow us to go through this process much more quickly.
557. Finally on this point, Dr Munday, in your
evidence you have certainly given the Committee the impression
that all is not well in Watford and you have spoken about the
fact that you wanted a consultant which was rejected, and then
just to stick the boot in they thought they would cut your budget
by £200,000 and so on and so forth. Could you give us a little
bit more detail?
(Dr Munday) We had a very successful service in the
early 1990s. We expanded. In 1991 we saw 5,500 patients; we had
2.7 full time equivalent doctors and 4.7 full time equivalent
nurses. After 1995/6, we had no additional funding and by 2001
we were seeing 17,000 patients with 3.7 full time doctors and
5.7 full time nurses. That is an increase of one doctor and one
nurse for an extra 10,000 patients. The situation became critical
in January of last year when we saw 35 per cent more patients
in January of that year as compared with January 2000. I went
to the chief executive for emergency help. I wrote to him; I e-mailed
him and I telephoned him on several occasions. I got no response.
After several weeks of continuing this and eventually threatening
to go to the media, he passed the problem on down to a senior
manager who had no ability to make financial decisions. I also
wrote to the director of public health and to the consultant for
communicable disease control locally. I tried to find a lead for
sexual health from the health authority but there was not one.
Meanwhile, several of my staff resigned and a couple of nurses
went on long term sick leave, meaning that we could not sustain
services. We had to keep closing doors because we just did not
have anyone to see patients. I went back to the trust board eventually
and asked for some support and they said they would talk to the
PCTs about the possibility of a new consultant post. That fell
through because it was not a priority in the local health economy.
Meanwhile, the trust structure has changed. There is a completely
new management team and the deficit in the local health economy
is such that everyone is being asked to make cuts. I have to close
down my outreach team which has been running successfully for
several years. I have already taken one of my outreach posts and
converted it into a health advice post. My final outreach worker
I managed to convert into some local consultant sessions which
lasted for eight months. I went back to the trust and said, "Can
I have another four months of money to keep this person in post
so that we can keep seven sessions open?" and they said,
"No." It has been one reverse after another. The local
health economy is in dire problems. It is one of the worst health
economies throughout England. Their priorities are first to balance
the budget and second to balance the budget and third to meet
targets around access, waiting times, cancer waits and framework
issues. There is no money left for us and we are having to make
savings in order to fund the deficit against a vastly increasing
workload.
Jim Dowd
558. You say that the trust has been in financial
difficulties for ten years or so but it looks as if things went
pretty well during the 1990s as the demand for increased services
grew and you were able to respond but the wheels seemed to come
off last January for some reason. Why then?
(Dr Munday) We have gone on increasing our patient
numbers within the framework which we had. We run an open access
service. That means the doors open at such a time and close at
such a time. We will see all the patients who appear during that
time. For example, on Monday, we do a morning session which will
be advertised at 9.30 to 12.30 and at 12.30 we close the doors
and there will be another 15 or 20 patients still to see. We finish
maybe at two o'clock and we reopen at 3.30. The real killing thing
is the evening sessions. By seven o'clock when we close the doors,
there will be 20 new patients to be seen. My nurses were sitting
around at 9.30 or ten o'clock, still seeing patients and they
just could not take it any longer. The thing which really hurt
us most was the fact that local clinics moved away from open access
to appointment sessions. Everyone said, "Go to Watford. That
is still open access. You will be seen in Watford." We were
seeing people from all over north London and the home counties.
It went on and on and we could no longer cope. It was a number
of factors which brought about that enormous increase in workload
over a short period of time.
559. The resources that the trust allocate to
you have been cut considerably since January last year. How does
it look incongruous that you are seeing 15 per cent more
people than you were last year?
(Dr Munday) Because my staff work very, very hard
to get them through the doors and out again. The quality of the
service has declined but we still feel that it is important to
maintain an open access service.
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