Examination of Witnesses (Questions 560-579)
THURSDAY 28 NOVEMBER 2002
DR GEORGE
KINGHORN, DR
PAT MUNDAY,
DR CHRIS
FORD, MS
MARIAN NICHOLSON,
MR GRAHAM
TAYLOR AND
MS JACKIE
ROGERS
560. The quantity has gone up but the quality
has deteriorated?
(Dr Munday) I think so. We cannot give the patients
the time that we used to and we are cutting corners all the time.
561. Is it an acceptable service that you are
providing?
(Dr Munday) Just about at the moment but we certainly
could not cope with any more. Of course we are now turning patients
away without seeing them—something which had never happened
in Watford until the middle of 2001.
(Dr Kinghorn) We have highly motivated staff who have
long worked in GUM clinics but you get to a stage whereby, despite
your best efforts, you feel that you are doing a bad job. That
is the worst thing when you go home. That is when morale suffers.
That is when you get sick. That is when you really do not want
to go into work to do another bad job on another day. You tend
to go off sick or have some sort of problem and that puts even
more pressure on the remaining staff. You get to a stage of melt
down. The situation we have within many GUM clinics which have
been extremely well run is that we are running a risk of melt
down.
John Austin
562. What does cutting corners mean?
(Dr Munday) It means spending less time on sexual
health promotion ultimately. It means giving them the treatment
and pushing them out so that you can see the next patient.
Chairman
563. Not preventing others coming in the future?
(Dr Munday) No.
Jim Dowd
564. On the broader question of skills shortages
and the problem of recruitment and retention across all kinds
of health service activities, is it any more acute in this branch
of medicine?
(Dr Kinghorn) Within the specialist service, we have
trained consultants for whom we do not have jobs at present. However,
in order that we improve sexual health care as a whole, there
must be an increased role for primary care. Teaching and training
in primary care is quite key. They need to have the time, the
resources and training. There is a skills shortage and a time
shortage within primary care at this present time.
565. Do you mean GPs?
(Dr Kinghorn) Yes.
566. The service needs to be decentralised.
(Dr Kinghorn) There needs to be extra emphasis both
on the core specialist service and additional services provided
within primary care. Many GPs—my wife is a GP—have
said, "We have so many pressures upon us at this moment in
time; how to fit this in seems to be very difficult." Many
GPs do not feel that they have the skills to deal with level one
services. We as specialists need to spend a lot more time giving
support and training to our colleagues in order that we can have
this augmented service within the specialist services and within
primary care in the future.
Dr Taylor: Dr Munday has highlighted
one of the most important messages we should be passing to the
government. Although everybody welcomes the large amount of extra
money that is coming it, it is being mopped up by deficits and
there is none left at the moment for the advances that are so
essential. I think that is one of the crucial messages that we
should be getting across so that people do not expect magic improvements
absolutely immediately.
Chairman
567. As this is being broadcast, if we have
young doctors or people who are doing medical training looking
in, one wonders what will attract them to this area of medicine
in future. What attracted you in the first place to come into
this area? If we have a better national agenda, what do you think
will bring people into this specialty in the future?
(Dr Kinghorn) We all started off in mainstream medicine.
The difficulty with medicine, certainly when I was in training,
was that so much effort was given to the management of end stage
disease. We were palliating most of the people we were looking
after. The great attraction of what we were doing in the specialty
of Genitourinary Medicine was that we were curing people and we
were working with a younger population. It mattered. The impact
of what we did was so much greater. I do not think that has changed.
We have also lived through the advent of HIV which has been very
much at the cutting edge and which has made the specialty attractive
to many very able, young doctors. I still think that the most
important thing is that many of the people we look after we cure
and it makes a very significant difference.
(Dr Ford) Primary care cannot take on this role if
there are not well supported specialist services to work in local
and regional networks. There are increasing pressures from every
direction on primary care and the strategy very much set a role
for primary care in there but it came with no new resources. We
cannot be expected to take on this added role without additional
resources. Sometimes people say it is primary care whingeing about
money. Our workload has gone up; patient demand has gone up and
if we are going to be able to do this effectively we very much
need resources, both financial and human. We do not have a consistent
training programme. As a medical student, I got no training around
sexual health. I have done some obviously but it is not given
emphasis in undergraduate and postgraduate training. There is
no consistency in that training and if we are going to take on
this role it is very important that that is addressed.
(Ms Nicholson) We hear from a lot of patients all
over the country with herpes simplex and we hear frequently that
a woman, when she goes to her GP with a sexual problem, an itch
or a pain, the doctor will say without any sort of examination,
"It is probably thrush", and give her a prescription
for Canestan. Since the doctor clearly has no competence in GU
medicine, at least he has spared the woman the embarrassment of
an examination. While some people do prefer to see their GP with
a sexual health matter, there is a high proportion of people who
really opt to go for the anonymity of a GUM service. That has
to be maintained quite separately from the primary care network.
We hear of people who will travel to nearby towns rather than
go to the clinic in their own town. This may be because they still
have open access but when they speak to us about it it is because
they want the guarantee of anonymity that going to a nearby town
would give them. We do hear of embarrassing incidents where a
patient goes to a GUM clinic and there is someone on the staff
who makes some sort of recognition comment. We are embarrassed
about sex in Britain with our prurient and puritanical attitude.
(Mr Taylor) The primary issue around primary care
is not one about decentralisation. It is about additionality.
There is no point in decentralising a service that works very
well. If we are going to look at developing primary care services,
we have to have training in place to help GPs and practice nurses
understand issues and to be knowledgeable about them. Then you
have to have space in which they can practise. If they already
have an existing case load, there may need to be additional space
in the GP practice. You also have the issue around the IT system.
If you are looking at contact tracing for people in the primary
care setting, finding their sexual partners, it is quite a hard
thing to do and it takes a lot of time. I do not think anyone
within the primary care setting has the additional facility at
the moment to do that. We have been looking at providing sexually
transmitted infection training for GP practices but then what?
You are going to need to have people working between the GUM service
and the primary care service on contact tracing. It is not as
simple as it might appear. Logically, if we can provide additional
services elsewhere other than in the GUM service, of course it
will reduce the pressure on the GUM service, but if you are going
to develop those services initially that means you take people
out of the GP setting and the GUM setting to provide the training.
Ironically, there is less time for you to see anybody so in the
short term you have fewer appointments available at a time when
you are trying to develop a service. It becomes quite difficult
and you cannot fund the additional service so you almost need
bridging funding to pay the people to come out of the GUM service
so that you can provide the training.
(Ms Rogers) I wanted to go back to recruitment and
retention of staff. It is difficult throughout the health service,
particularly for nurses. Having got the nurses in your service,
it is then keeping them there because there is no career pathway.
That is becoming a big issue for some clinics, certainly within
city centres where they can move from clinic to clinic. They find
that they are all inundated with work and it is not rewarding.
We need to start to equip nurses and to make them think about
sexual health pre-registration. It should come into their training
anyway. We need to have the resources so that we can relieve nurses
so they can go off to do post-registration training and we need
to look at a career pathway for them.
568. You say this should come into the training,
implying it does not currently.
(Ms Rogers) It is touched on.
(Dr Ford) People should retain the ability to go somewhere
anonymous but it has a negative effect as well. If we look at
what happened to HIV, it was special and different. It went to
a consultant. Do not talk to those naughty GPs because they do
not know anything about it. It has taken us 15 years and we have
moved on from that. Most of us in general practice are managing
a lot of HIV care. HIV is a chronic, relapsing condition, which
we are quite good at dealing with in primary care. The example
used about thrush is bad medicine. That may be to do with ignorance,
lack of training or whatever but I would like to change that.
If that person went with a discharge, they should see somebody
who knows what it might be and who is able to take effective swabs.
If they cannot deal with it, then they should refer on to a specialist.
That is what happens in all other specialities. When I cannot
manage it, I send it on to a man or woman who can. It seems slightly
bizarre that we have a different model in a few subjects, one
of them being GUM. To be able to do that, primary care has to
have the right screening and testing facilities. In the surgery
where I work, the chlamydia screening I use, if you are very good
at it, can pick up about 60 per cent. If you go to the
local specialist, they say they have a test that if you waft it
anywhere near the part chlamydia will be picked up. It is completely
bizarre that I as the less experienced practitioner have to use
a poor test. Nobody else would recommend supporting a test that
only picked up 60% of, for example, HIV, why so for chlamydia?.
We should have effective screening and diagnostic facilities available
in primary care.
569. While we are on the relationship between
primary and acute sectors, can I throw in an issue that this Committee
has looked at? It may be completely irrelevant but is there any
use of telehealth and teleconsultations at all within your area
of work? Do you know of any primary care centres that may connect
with local GUM specialists in a nearby acute hospital? Does it
have any potential or is it completely irrelevant to what you
are doing? I would have thought it may have some potential to
assist a patient having to travel miles from where you are based
to see someone like Dr Kinghorn or Dr Munday.
(Dr Ford) I think it is an excellent idea but it takes
an enormous amount of resources. You have to have somebody at
the other end who is not seeing 25 patients at the same time.
570. It could be used, as far as you are concerned?
(Dr Ford) Yes, in the right situation.
571. I was at a conference yesterday where we
were looking at telehealth and it struck me also on the issue
of the embarrassment side for patients avoiding having to sit
in the kind of place in Manchester where you might even see a
groups of MPs wandering around the clinic.
(Dr Ford) I have an example where, if the treatment
for chlamydia changed, that would be kept up as a dialogue between
the consultant and an e-group and it would be very helpful to
have that in our area.
(Dr Munday) There is one particular problem in relation
to GPs which has a training outcome. Patients with STDs do not
go with a label saying, "I am a patient with an STD."
They go with gynaecological symptoms and urological symptoms.
Many people do not think STIs; they think gynaecology. A woman
may turn up with some sort of minor gynaecological symptom and
she is sent for a scan or she is booked into a gynae clinic in
several weeks' time. The GP does not think: this is a 19 year
old patient. She is on the pill. She must be sexually active.
Let us rule out GUM problems first. There is a big educational
issue there to make GPs and gynaecologists think in a slightly
different way. If we could do that, that would help tremendously
in a symptomatic patient. Screening is fine but there are a lot
of patients who have symptoms who are not being appropriately
diagnosed.
(Dr Kinghorn) The need for improved communications
and the use of all the media available to us for that purpose
is fine; also using the internet. I am sure there are many things
that can be done. There is one big issue about teleconsultations
and that is patient acceptability.
Dr Naysmith
572. This Committee has had quite a few representations
about chlamydia recently and we are thinking about the possible
expansion of chlamydia screening. What Dr Ford has just said is
a real in to what we want to find out a bit more about because
I am sure Dr Munday and Dr Kinghorn will want to reply to her
suggestion that you are dismissing what you do in general practice
as being not quite to the same standard as you do. What is the
real answer about the sensitivity of the different tests in different
places for chlamydia?
(Dr Kinghorn) There are two common tests. One is called
enzyme immunoassay and in the Portsmouth studies it was found
that it picked up between 50 and 75 per cent of the positive
patients as compared with the molecular test. The molecular or
nucleic acid amplification tests are more expensive but they will
pick up more cases from those people who are screened and one
can use samples such as urine or a swab "somewhere near the
relevant part" in order to make a diagnosis. For us to be
continuing with a suboptimal test is iniquitous. In Portsmouth,
following the completion of their study—and they had very
strong evidence for using the molecular test—they had to
go back to using the suboptimal test on the patients that they
are looking after. That, to me, is wicked. It is a situation which
prevails across the country. There should be no argument. The
evidence from everywhere says very clearly that this molecular
test is so much better.
573. What proportion of the tests nowadays are
the most accurate?
(Dr Kinghorn) No more than 30 per cent of the
clinics in the country have the most accurate test available to
them. The majority of people who are presenting for screening
are being screened by this suboptimal test.
574. Are you talking about GU clinics?
(Dr Kinghorn) Yes. In general practice, I would suggest
that less than five per cent of GPs have this test available
to them. We have that problem with chlamydia screening. Many of
us who have been looking at chlamydia screening and talking about
it for the past 25 years cannot believe how long it has taken
to do the obvious. The obvious is that there needs to be use of
the appropriate test with as wide a coverage as possible.
575. Why is it not happening?
(Ms Nicholson) Money.
576. Presumably clinics have control of their
own budget once it has been given to them. If they think this
is really important, why do they not use the most sensitive test?
(Dr Kinghorn) If you have a finite budget, if the
test costs more, you may have to reduce the number of practitioners.
I often have to make a choice between treatment of patients, particularly
with HIV, tests and staff. We have indicated that people are so
crucial to us in terms of developing these networks. The argument
in terms of chlamydia screening and the wider availability of
these sensitive tests, although there would be an increase in
costs, is irrefutable and it must be cost effective to do it this
way.
(Dr Ford) I would agree. Chlamydia is so often asymptomatic.
In practice, I have to decide, if I am seeing somebody who is
in a high risk group, do I offer no screening or screening or
do I send them to my friendly consultant who I know might have
a three week waiting list and who the patient may not go to see.
It is a choice that I should not have to make. I am making a choice
about that woman's health and her future fertility. We have written
to our PCT and said that it is professionally negligent that we
cannot provide this. We have not had a response yet but they have
said they are looking at it positively. Like Dr Kinghorn was saying,
if you provide that, you have to take it out of somewhere else
because it is a finite budget.
577. One of the issues this brings up is that
if the more sensitive test was used more widely it would create
a lot more pressure on the service which already is not dealing
with matters well. It is not sensible use, is it?
(Dr Kinghorn) It is not the service that matters most;
it is the people that we are looking after. We are letting down
people, young people in particular. Even when they have the courage
to come and see us, we are offering a suboptimal test. That is
the tragedy. It is a problem that the more screening that is done
and the more aware people are then more people will require GUM
services. Service capacity must be increased.
578. Since chlamydia is asymptomatic, you are
going to be picking up lots of people who do not even know they
have a sexually transmitted infection.
(Dr Kinghorn) A proportion of those people are going
to go on to develop complications and tubal damage and will present
for infertility treatment services in the future. There is also
the risk that they will transmit it to somebody else who will
develop those complications quickly.
(Dr Ford) The two pilots for chlamydia in Portsmouth
and The Wirral showed that you can do this very effectively in
general practice. There was a good pick-up rate, good screening
and good treatment. There is no point in screening for it if you
do not do anything about it. It is a great sadness that of the
new pilots none of those is based in primary care. The pilots
did show that it can be done in general practice, if you have
the right training equipment and support. It can be done very
effectively in primary care and it is a real sadness that none
of those pilots is going to happen in primary care.
579. One of the consultants we spoke to in Manchester
said they needed a national roll out for a chlamydia screening
programme like a hole in the head. Is that a fair comment?
(Dr Munday) We need a chlamydia screening programme
and we are going to have to cope with it, one way or another.
We cannot deny patients the opportunity to be tested for the commonest
sexually transmitted disease, which is preventable and which is
going to affect their future reproductive health.
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