Examination of Witnesses (Questions 580-599)
THURSDAY 28 NOVEMBER 2002
DR GEORGE
KINGHORN, DR
PAT MUNDAY,
DR CHRIS
FORD, MS
MARIAN NICHOLSON,
MR GRAHAM
TAYLOR AND
MS JACKIE
ROGERS
580. Do you think there is room for a lot more
scope in general practice for this kind of thing?
(Dr Munday) I do. I would like to see screening much
more widespread, not only in general practice but in family planning
clinics and gynaecological services where, even now, chlamydia
testing is not widespread before invasive procedures such as treating
a cervix when people have abnormal cervical cells. Quite often,
those are young people and they are not being screened for chlamydia
before they have that invasive procedure done.
(Dr Ford) If we look at cervical screening and what
has happened in primary care and general practice, there is a
national cervical screening which did not happen before there
were certain things such as equipment and resources put in place.
We can rise to the challenge as long as those things are put in
place and chlamydia would fit very nicely into the model that
they use for cervical screening. I am not quite sure why that
was not done. Most of the people who present to GUM services have
put themselves at risk, and think they have a problem or have
symptoms. People present to us every day and we can screen appropriate
people if we have the resources but we can certainly screen high
risk groups who may not know they have the infection.
Julia Drown
581. The fact that the better test is not used
seems to indicate a failure of decision making somewhere in the
NHS. I appreciate patients are not being well represented but
can any of you indicate where exactly the problem lies? You point
out that there will be savings in the gynaecological sector if
you pick up chlamydia early, so is it that you, combined with
gynaecological colleagues, say, "Yes, this should be a priority
of the trust so that it gets on the trust board papers",
amongst other things, or is it trust board members not taking
responsibility for this or does it not even get that far?
(Dr Kinghorn) Undoubtedly, some of the problem must
reside with doctors who are often not clear about what should
be relatively simple messages. They may find themselves in a competitive
situation over what happens within their respective services,
particularly if you are in a situation where there are finite
resources. In the current world, we have to discuss these issues
not only within our trust but also with commissioners. It is very
important that our commissioners should be receptive because they
are going to be the referees within this particular process. It
is not about squabbling doctors; it is about making the right
sort of priorities. Since 1997, sexual health has been taking
over the priorities. It was in Health of the Nation; there was
a sexual health priority. Now, many commissioners believe it is
only those priorities which matter.
582. In pure finance terms, for the commissioners
it is even more relevant than the trust. If they can save money
in gynaecology, you would expect them to be jumping at the chance
to do so.
(Dr Ford) Is this not one topic that should be taken
nationally? The HIV test is national. If you had an HIV test that
picked up 60 per cent and one that was a little bit more
expensive and picked up 99 per cent, which one would you
do? It should not be something that comes down to the local PCT
area.
583. At one level I would agree but at another
level would you not expect the responsible managers throughout
the health service to be able to make that common sense judgment
themselves? Those same managers are the ones who complain about
directive after directive after directive coming from the centre.
Do we really need to have directives about using the best test,
particularly when they are picking up serious infections that
can lead the health service to spend more money in the future?
(Dr Ford) I think so, yes.
(Dr Kinghorn) Yes.
584. The government is talking about more devolution
to trusts, not less!
(Dr Kinghorn) The argument is can you leave this to
local decision making. For matters of public health, I argue you
cannot. There will be some who will understand this but there
will be others who do not and because we are dealing with transmittable
disorders there has to be direction from the centre. Otherwise,
the same problems that we are talking about today will continue.
The worry that I have is that the country will pay happily for
HIV testing. It will pay for end stage disease because that has
always been done yet the prevention of the expense for the future
will be something which will not be seen so much as a priority.
(Mr Taylor) Locally, we have a sensitive test for
chlamydia and in reality it does increase the number of people
attending the service. If it is decided to make it a priority
locally, in the next breath I get the GUM and HIV service saying,
"We do not have enough capacity." That is because of
finite resources. I take your point entirely. Yes, there will
be a saving in some other service but the connection between HIV,
STIs and gynaecological services does not always exist. The person
who commissions one service does not necessarily commission the
other. I agree with you. I am very happy to push that but the
allocation that goes to the combined hospital trust is a big lump
of money. It is not broken down and that is how it becomes quite
difficult to say, "There will be a £50,000 saving there;
therefore, let's transfer it over here." If only it were
that simple, I can assure you that my health service colleagues
would have done it by now. Do we want more directives in the NHS?
If I say yes, my colleagues will kill me. If I say no, the patients
will be very upset and angry and so will my clinical colleagues.
The reality is that there need to be priorities set nationally
for certain things. Some of those have to be around transmission
of infections, which should not be up to local decision makers.
Also, I do not necessarily think that people will automatically
be happy to fund HIV treatment and care because there are a lot
of people who are not. When I am trying to find money for HIV
treatment and care, it is always a battle at a national level.
The allocation process means we do not get the funding for at
least a year after we have had to start paying for it. Therefore,
local PCTs have to club together to try to find that money. If
you are part of a health authority with a very large budget, it
is slightly easier than if you are a PCT where the percentage
you need to fund is very hard to find. It is not so simple.
585. It is certainly not simple for us as a
Committee to hear that managers want fewer directives and targets
and yet here we are, hearing quite the opposite. However, Jackie,
are there any legal barriers or folklore barriers that stop nurses
being able to be more active and take a bigger part in clinics?
Your own clinic has nurses taking a full part and doing treatment
and prescribing, presumably. Is that the case across the country?
(Ms Rogers) There are no legal barriers. It is about
equipping them to do the job.
586. It is about skills training?
(Ms Rogers) Yes.
Julia Drown: It is not that we need another
directive. Excellent.
Jim Dowd: I wonder whether a national
chlamydia screening programme should be made a priority or can
it wait?
Chairman: This is before the pilots are
completed?
Jim Dowd
587. Yes.
(Dr Kinghorn) I would argue that it should be a priority.
Any of us who have children below the age of 25 would argue that
it should be a priority. The arguments for screening have been
accepted by the National Screening Committee. The issues that
are important are coverage and sensitivity of the test. We find
it very difficult to understand why we are rolling out in dribs
and drabs in this suboptimal way.
Julia Drown
588. Are the physical environment facilities
across the country worse than the average NHS state? Is there
a case for saying that conditions within GUM facilities should
be a priority in terms of physical improvement of the environment
and equipment?
(Dr Munday) There was a lot of improvement in the
early 1990s. Many new buildings were constructed. In general,
the state of GU medicine is probably not bad overall. There are
possibly notable exceptions to that. The problem is capacity.
The buildings which were constructed in the early 1990s were for
workloads of the early 1990s, not for workloads today. We have
real difficulty moving people through the clinics because we do
not have enough clinic rooms. We do not have the physical space
to move them around. We have looked at lots of models to try and
facilitate movement, but we have a barrier because we do not have
enough clinical rooms.
589. That would be worse in other specialties?
(Dr Munday) I am sure it is the same throughout clinics.
590. It would be worse in other specialties
within your trust?
(Dr Munday) GU medicine is rather different because
we do everything in one building. We do all our history taking,
our examination, our investigations in one block. Out-patients
departments, for example, are upgraded once every ten years or
so. All specialties that use routine out-patients will get their
routine upgrade every ten years. We are a bit outside that system
and we would have to bid separately to get an upgrade outside
the routine system.
(Ms Rogers) There is also an issue about integrated
clinics because we are being encouraged now through the strategy
to integrate sexual health. The idea is to have one centre in
one town, for instance, where people can get a one-stop service.
We can hardly cope with the physical problems that we have now
with GU. If we start to push family planning and the other services
through that same clinic building, it will be impossible.
(Mr Taylor) Jackie and I coincidentally work in the
same part of the country. In an urbanised area, Brighton and Hove,
the contraceptive service is provided by a different trust in
a different part of the city, whereas the GUM service is somewhere
else altogether. Trying to combine those two different services
on one site is difficult as there is not the room for it nor the
money for it. However, in relation to other parts of the county,
they are integrated services more or less but the reality is that,
although they are integrated, they may be sharing a building with
somebody else. The queue out of the HIV/GUM/STI service goes right
across another service. If you are worried about confidentiality,
you do not want to be queuing in a different bit of the service
as well.
591. There is not a clear message. There is
a message saying that you need bigger facilities. You are an exceptional
case and there are other pressures in the health service. What
we have had in terms of evidence coming through and the question
for you is: is this a pattern or not? Is the service being provided
from Portakabins? Is that widespread? We had Wolverton Clinic
in Kingston telling us they lacked sinks in some clinical rooms
which seems pretty shocking. How much are these the exceptions
or how much is this the rule that the GUM physical state in the
health service is worse than others?
(Dr Kinghorn) Our specialist society did a survey
in April 2001 and we reviewed all clinics within England to assess
their needs. We were looking at the question of accessibility,
acceptability and effectiveness and whether that was compromised
by inadequate premises. Refurbishments and extensions were probably
needed for about 80 per cent of clinics and there is often
the problem of inadequate space. About 20 per cent are
Portakabins and worse. Some of them have been in the health service
for many years, even decades. We need to rebuild these clinics.
There is a need for investment in IT. Many clinics are not hooked
up to laboratories. They have not been included in the general
hospital upgrades that have taken place. We have a tremendous
problem with clinical records because we have to keep our records
separately. Finding space for those records is an absolute nightmare.
We would like to see a comprehensive review of all clinic facilities
as a matter of urgency.
Mr Amess
592. The government's strategy for sexual health
is an ambitious one and they want it implemented within two years.
I think a specialist has described the £47.5 million that
has been earmarked for this as paltry. I suspect we know how you
are all going to answer this question but for the record how do
you feel about this £47.5 million? Can it be done?
(Dr Kinghorn) We always welcome anything that provides
a start. We have a very ambitious target by 2007 of reducing the
number of new cases of HIV by 25 per cent. We know that
the cost benefit of preventing one case of HIV is somewhere between
£0.5 and one million according to the strategy document.
If we prevent 25 per cent of those that occurred last year,
that is over 1,000, the benefit on an annual basis is between
half and £1 billion. I am arguing that the price to implement
the strategy properly is well in excess of the £47.5
million which has been made available to us so far. The cost of
not doing so is going to be far greater.
Dr Taylor
593. Can we turn to primary care? Whenever changes
in the health service are made, it is always rather assumed that
it is left to the GPs to pick up the tab and this is very much
so in this service. You have given us an absolutely excellent
paper which has outlined the problems and the solutions. Have
you any clues about how the new GP contract is going to address
the need for GPs to be taking on extra training and extra specialist
services, not only in GUM but in other things as well?
(Dr Ford) We have been trying to find out what is
going on with the GP contract. It is one area that is needing
a central remit or whatever. The new GP contract is either going
to change general practice completely or destroy it. I feel very
positive about it but it should change the way that we work. We
are moving away from the shopkeeper on the corner to looking at
needs assessment of a population and quality markers. It is a
positive move. The core services of the new contact are acute
medicine and terminal care. Additional services, which are a large
bulk of general practice, already provide vaccinations and management
of chronic, relapsing conditions, asthma, diabetes and things
like that, are things that we will need to provide or have a very
good reason to opt out.[2]
From what we know at the moment, it looks as if the only thing
that is going to be mentioned in additional services is contraception.
We are not quite sure whether sexual health is going to end up
an additional or enhanced. If sexual health ends up in enhanced,
we are into a real difficult position. We have to get the sexual
health strategy moving forward which is about seeing sexual health,
not contraception, as a mainstream function of general practice.
It is wrong that if somebody goes into a GP or a family planning
or contraceptive service and says, "I want contraception"
that they do not get a sexual health history or a risk assessment.
We have to move away from seeing it as something special and different
to the core of our function. If you can take a good sexual health
history, you can pick up an enormous amount of other things about
sexual wellbeing as well as sexually transmitted infections. In
some way, we have to ensure that it is in the main bulk of the
GP contract with quality standards because one of the other things
being introduced in the contract is quality standards. I love
general practice but it is very peculiar. Somebody said the only
consistency of general practice is its inconsistency. The GP contract
potentially can move that forward, but we need some standardisation
in what is provided in primary care. We have talked about training
and we need good screening and diagnostic facilities and we have
to think about data collection. In primary care we do not collect
data around STIs. Somebody mentioned partner notification. There
is not any way that we can do partner notification in primary
care. It depends, to me, on having a good clinical network and
that potentially can happen. The move should be towards sexual
health services rather than contraception here and GUM there,
with primary care being in the centre, so that we know where we
can get help when we need it.
Dr Taylor: That is most helpful. I hope your
paper will be an integral part of our report.
Chairman
594. On the last point you made about attempting
to have a wider sexual health arrangement, would you apply that
to the way in which we separate GUM in an effort to try and make
it more attractive for people to attend and less embarrassing?
If we were to broaden the functions, would that be helpful in
general terms?
(Dr Ford) Yes. If you are going somewhere about your
sexual health, it does not necessarily mean you have one of those
diseases. If you go and see your GP about anything, it is about
looking at your sexual health. If you want contraception, contraception
may be one thing. screening may be another. We need to bring it
all together. We need to work much more in partnership. Our local
GUM clinic sends reply letters to GPs very infrequently. We send
a lot of people there. I question that. Specialists need to support
what we are doing and we need to be able to do what we are doing
more effectively.
Dr Taylor
595. You make the point that at present all
prescriptions are charged except contraception. Is that a major
problem to the people with STIs?
(Dr Ford) It is. If you go to a GUM clinic, you get
your doxycycline and you do not have to pay. In general practice,
you have to pay nearly £7 now. This makes an enormous difference,
particularly to young people. That has to change.
596. Going on to the commissioning of sexual
health services, at several of our evidence gathering sessions
we have been bothered about the responsibility of PCTs and I think
one of you said they are thoroughly inexperienced at this. Can
you give us a flavour of how this is progressing, not only in
your area but if you have any ideas elsewhere? Are leads being
appointed within all primary care trusts? How are they functioning?
(Mr Taylor) I do not think I am sufficiently qualified
to comment on behalf of all PCTs across the country. Locally,
there is a lead commissioner and that is myself. I commission
services on behalf of East Sussex, Brighton and Hove. The other
PCTs have agreed that that is what I will do on their behalf.
597. How many PCTs?
(Mr Taylor) There is one for Brighton and Hove and
four for East Sussex.
598. You are commissioning for five PCTs?
(Mr Taylor) Yes. My colleague commissions for West
Sussex and he commissions for five as well.
599. Do the other four feel in any way disadvantaged,
as far as you know, your own PCT excluded?
(Ms Rogers) No.
(Mr Taylor) I am doing my best to spend a lot of time
with my PCT colleagues across the county because each local PCT
also has to have a lead sexual health and HIV person. Consequently,
when I am trying to find a way into the local PCT, I would use
that person. In Hastings, it is Jackie.
2 Note by witness: The third grouping is called
enhanced and this will be more of an `opt in' system. Back
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