Examination of Witnesses (Questions 600-619)
THURSDAY 28 NOVEMBER 2002
DR GEORGE
KINGHORN, DR
PAT MUNDAY,
DR CHRIS
FORD, MS
MARIAN NICHOLSON,
MR GRAHAM
TAYLOR AND
MS JACKIE
ROGERS
600. Even though a PCT is not commissioning
itself, it has to have a lead officer?
(Mr Taylor) That is my understanding. It is not clear
from the strategy itself or the directives coming from the Department
of Health. What it means essentially is that those local PCT leads,
whether they are a lead commissioner or whether they are linking
into a lead commissioner will need a "local" PCT lead.
There is an issue around the variability of experience of those
lead PCT commissioners, not in Jackie's case but in some of my
colleagues' cases they may have a very large remit of other issues
to deal with and sexual health and HIV are bolted on at the end
of that list.
601. To the other members of the panel, have
the PCTs all got their lead officers in place?
(Dr Munday) No.
(Mr Taylor) Ironically, the Department of Health wrote
to the PCT in Brighton and Hove and said, "Who is your lead
commissioner?" I wrote back and said, "You already know
but you have obviously not got the list." They said, "It
is very interesting because the Department of Health does not
know all the lead PCT commissioners because they have not been
told." Sometimes the information might not have reached them
or it has reached them and they have not coordinated the list
yet.
602. Frank Dobson told us that the Department
of Health is an information free zone.
(Mr Taylor) I do not know what to say to that.
603. We have had a lot of talk about national
service frameworks at all of our meetings because it is obvious
those people without them feel desperately penalised and it is
also obvious that you are not going to get one for years and years
to come, or at least three. What is the answer to that? How do
you raise your claims without having an NSF?
(Dr Kinghorn) I do not think we have time to wait
for an NSF in three years' time. We have to do the job anyway.
We need as much support as we can get from the government but
it is very clear that we have to do a lot of work ourselves, working
together. This is why doing it on a piecemeal basis, PCT by PCT,
takes too long. We cannot wait for local priorities and local
needs assessments to do this job.
604. This is where we come to in, absolutely
hammering this home.
(Mr Taylor) There is an issue about lead consortia
arrangements. You might have one PCT commissioning on behalf of
a whole range of PCTs to share the financial risk around additional
staff needed and so on and that, I suspect, is what will happen.
A commissioning toolkit which identifies a whole set of options
and priorities hopefully will become available before Christmas.
I am hoping that it will because it is very key that we get the
commissioning toolkit out as soon as possible or clinical colleagues
and myself will find it very hard to identify how things are going
to be commissioned and what process we should be following.
605. Are you talking about a larger group than
five PCTs?
(Mr Taylor) Yes.
606. What sort of size?
(Mr Taylor) It will depend on the nature of the epidemiology
in the area. If you have London, you are not necessarily going
to want a new consortium arrangement for the whole of London.
Already there are a number of consortia arrangements for example
south west London but in other parts of the country there seems
to be a perception that nobody has sex outside of London and if
you go outside the urban areas nothing much is happening. If you
looking at lead consortia arrangements, they may well depend exactly
on the size of the population you are dealing with and the epidemiology.
607. Strategic health authorities would be too
big?
(Mr Taylor) Potentially; not necessarily.
Julia Drown
608. The British Association of Social Workers
and the Special Interest Group on HIV and Sexual Health have suggested
that general practice has not shown itself to be free of the prejudice
about HIV. How real a danger is there that those accessing services
in primary care will come across that prejudice, particularly
for HIV positive men and women and for young teenagers who want
to access sexual health services? Is it true that they would be
more likely to encounter prejudice in primary care than in specialist
services?
(Dr Ford) I do not think that is true at all. We have
disclosure and satisfaction rates from HIV positive people using
GPs and this has been done in a lot of places. Most HIV people
do disclose their positivity to their general practitioner. They
feel that they get a good service and there is a bit of a myth
that you are always going to get a bad attitude. I know some of
my colleagues have appalling attitudes, but that can happen in
any area of medicine, not just in general practice. I think a
lot of that comes from ignorance. If you are frightened about
something you tend to be more ignorant. It comes back to training.
Certainly in work we have done around drug dependency, if you
actually get general practitioners to feel confident working with
drug users—You don't have to try and protect yourself and
say, "you are a dirty scumbag, stay away". It is not
rocket science. In HIV care some of the medications are rocket
science but actually the management of HIV is not rocket science
and we can manage it. I think one issue that needs to be resolved
that we have been banging on about from the college is actually
around confidentiality and insurance. We are the only general
practitioners in the world (I think), certainly in Europe, who
provide information to third parties. If you want to take out
a mortgage, the mortgage company asks me for your information
and I send it to them and they can send it to other companies.
I think that is a real problem that we need to address in general
practice, and we are trying to address it, but it would be nice
to have some help centrally to actually say that you cannot be
an advocate for somebody as well as disclosing confidential information
to third parties.
609. So what is the solution to that?
(Dr Ford) Because general practice groups do not want
to lose funds, if you have a patient who wants a mortgage report
then you send them to me (although I never do them). You could
have GPs doing it but they would not be their registered GPs.
It would solve it incredibly easily and everybody would be happy.
General practice is inconsistent but we are improving with standardisation,
with minimum standards of care, and certainly we have produced
minimum standards of care around sexual health and HIV care from
the college group that we hope will be sent out to all general
practitioners.
(Mr Taylor) Just to echo that, we did some local surveys
of Brighton and Hove around attitudes towards shared care arrangements
between GUM services and the GP practice and the statistics seemed
to indicate that the longer that you are HIV positive and the
more you use your GP practice, unsurprisingly the happier you
become about using the GP practice. The issue is almost about
a perception of what the GP, the practice nurse or the receptionist
is going to say or do. That is a very deep seated view and it
is very hard to unpick it. Irrespective of whether insurance companies
will identify whether somebody has had an HIV test or not, the
perception is that it is the case, so consequently it is a self-fulling
prophecy. People will not generally go to their GP because they
are scared and that has nothing to do with the attitude of the
GP necessarily, it is about, "If I disclose here then is
my insurance ruined for the rest of my life?" It is a very,
very difficult issue but it does not necessarily have to be, as
my colleague just said. It is about being clear about expectations,
being clear what the shared care arrangement is and making sure
that in some circumstances where it is not working then the patient
and/or the GP is not penalised but is helped to understand what
should be happening.
610. It is about giving patients the confidence
that they can have confidentiality and that information does not
go any further?
(Mr Taylor) Yes.
Julia Drown: I know you want to come in, Marian,
but in responding would you also deal with the issue about anonymity
because I would be interested in your perspective about whether
you think patients would always prefer to go to a GUM clinic rather
than discuss with their GP conditions that they might be embarrassed
about?
Chairman
611. Can I ask a point I raised earlier, whether
we ought to retitle or restructure the nature of these clinics
to make it a wider group of patients who are being treated and,
therefore, more acceptable to people?
(Ms Nicholson) I believe the North East did a survey
on this and they found that although a good proportion of people
were happy to have GUM and family planning services provided from
their primary service, a lot of them, for both family planning
and sexual health, wanted the anonymity of the separate clinic.
I cannot see any reason why you cannot put the two of them together,
which might be beneficial, but I do not know that that survey
has been done. I wanted to point out that a lot of our members
will not let their GPs know that they have a sexually transmitted
disease. It may be that the GP would be perfectly comfortable
with it but, as my colleague said, it is perceived that the GP
will be critical or judgmental about it. Remember that sexual
conditions can be picked up outside of a marriage situation and
the GP will usually be the GP for both the partners, so people
have to have the ability to go to an anonymous service. I wanted
to pick up on the point of the reports from GPs being sent to
companies for insurance and mortgage cover policies. I had a chat
this week with the spokesperson from the Association of British
Insurers and they have been looking at new ways of getting the
information that the insurance companies want without actually
asking a question about sexual health in too broad a term. They
agreed the list was too long to either exclude or include particular
sexually transmitted infections. We came up with the suggestion
that this committee be asked to make a statement in their report
that `it would be helpful if the insurance industry does not penalise
people for getting STI check-ups' because that is the issue, that
people who are taking care of their health and getting frequent
annual MOTs have to declare this and this could penalise them,
or they perceive that it would penalise them. Another way this
could be expressed that we came up with was `insurance companies
should find a better way of assessing the health risk to their
clients from sexually transmitted diseases' because that, after
all, is what the insurance companies want. They do not actually
care about the disease itself since most sexually transmitted
diseases can actually be treated, it is an indicator of the general
lifestyle that they are after, but they have not found a way of
asking the lifestyle question without bringing in these other
points.
Andy Burnham
612. Can I ask a couple of questions about,
firstly, sexual health inequalities and then the voluntary sector.
On health inequalities, am I right in thinking that some of the
problems we have been describing today are not uniform across
the country but the pressure on services tends to be focused on
particular parts of the country? Just going on from that, is that
partly due to the fact that there is a very strong link between
social deprivation and all the problems we have been discussing,
sexually transmitted infections, teenage pregnancies? Is it that
link that we need to get underneath, as it were, and address?
Does anybody have a view on that?
(Dr Kinghorn) Undoubtedly sexually transmitted diseases,
unwanted teenage pregnancies, social deprivation, inequalities,
these go together. The greatest pressures from sexually transmitted
diseases have always been traditionally in the large urban areas.
However, the pressures now, the pressures that we described earlier,
are right the way across the country in urban and rural areas.
I know of no clinics that have got any slack at the moment, the
screams of anguish are being heard throughout the whole of the
country. Dealing with the essence of your question, yes, we do
have to realise that those who are from the most deprived communities
are those with the greatest needs in terms of sexual health and
it is very important for us, I think, to react in a different
way. It is certainly the case that a centralised service may be
more inaccessible for those people who live in the most deprived
areas of the bigger towns and cities and for that reason our strategy
for the future has to be maintaining that service but having outreach
from that core facility in order to try and better meet those
needs.
613. Is there any evidence that people are more
likely not to be registered with a GP as well?
(Dr Kinghorn) Yes.
614. You are talking about people who are not
likely to access health services?
(Dr Kinghorn) This is a major problem. To emphasise
the point I was making earlier, there are many individuals who
do not access other health services. For them the opportunity
is now, service responsiveness has to be immediate. We have to
be able to respond to that need otherwise they will be forever
lost to the service. This is particularly true of the young. We
still see many individuals who do not access services elsewhere.
615. Dr Ford, you mentioned earlier about the
Sexual Health Strategy being too narrowly focused. What would
you like to see there to try and break this link between deprivation
and sexual health? What kinds of things would you have wanted
to have seen in that Strategy? What kind of approach would you
have wanted?
(Dr Ford) That is a small question! If it had started
with something more about the positive things around how sexual
health is part of our whole well being and what other things can
affect our well being in terms of deprivation and housing. I know
that we cannot solve all of those but somehow putting it into
a context rather than just medicalising it.
616. How you treat it?
(Dr Ford) Yes. Just going for the "let us treat
it", you have not looked at the causes of it, so more around
perhaps looking at the causes.
617. Is not part of the problem that that goes
well beyond the remit of the NHS?
(Dr Ford) Absolutely, completely, yes.
(Mr Taylor) I think there are some lessons also to
be learned from the Teenage Pregnancy Strategy which might be
criticised on a whole set of different levels on which I am not
intending to criticise it today. Quite clearly the Teenage Pregnancy
Strategy identifies a whole set of people who need to be involved
in discussions around teenage conceptions. The same issues apply
post-18 as they do before 18. What is very interesting in the
Teenage Pregnancy Strategy is the Partnership Board consists of
a whole range of different organisations not just from the NHS
but from the local authority, from the voluntary sector, from
youth services and from a whole range of other settings and the
reality is that the Sexual Health Strategy is actually a Sexual
Ill-Health Strategy because it is targeting STI so we are looking
at the end product of a whole set of social deprivation. Consequently
we need to be looking more clearly at why people are taking choices
in the first place so, yes, I would suggest that we might want
to look at the Teenage Pregnancy Strategy and how that works.
I am not saying it has been altogether successful but quite clearly
the partnership arrangements involving education, involving youth
services and urban regeneration funding and all the rest are more
likely to tackle the issue than a Sexual Health Strategy per
se focuses on STI and HIV transmission. That is not a criticisms
of the strategy but it just needs to be broadened out a little
bit. That is, I suspect, what PCTs will be having to do as part
of looking after their local populations.
(Ms Rogers) I work in a recognised area of social
deprivation so I have first-hand knowledge of how we are trying
to manage. Certainly I think that Graham is right, the model of
Teenage Pregnancy Unit has flagged up, and we are using, partnership.
We are doing a great deal of partnership work and it has been
very successful. At the moment we have got a teenage conception
rate of 44 per cent higher, one of the highest in the country,
and so we have been targeting young people particularly and we
have been doing a lot of work from the clinic with youth services
and primary care and education, and it works well because they
are sign-posting to our department but, as I have already said,
our department is a part-time department and so there is no core
funding money. They are throwing us all these patients and quite
rightly particularly young people are turning up, it is very successful,
but we cannot manage the numbers we have so it falls down there.
618. So the basic approach may be good but it
is the capacity of the system to deal with what it throws up.
(Ms Rogers) Yes.
(Dr Kinghorn) That which goes first when you are in
a pressurised service is this sort of outreach and preventative
work, and that is a major problem. All of us, to come back to
what Dr Munday described before, have had to cutback on outreach
and preventative work because of the pressure just to see patients.
It is really quite key for the future, as is the involvement that
was discussed before with teaching and training. Clinics have
more than just a function of treating patients when they have
problems.
(Dr Munday) Could I come back to your first question
about why it is we are seeing pressures right throughout the community,
and not just in deprived areas. I believe that is due to health-seeking
behaviour amongst middle-class communities. Although the deprived
areas are seeing people with very high levels of STIs we are seeing
very high levels of demand in areas where people are actively
seeking improved health care. That has been promoted by many of
the women's magazines for example which are read by articulate,
young adults and so they are going for their health checks. Many
of those people do have chlamydia and other sexually transmitted
infections, it is just the prevalence is lower and you have to
screen more people to pick up the cases. Those people are just
as entitled to have their chlamydia diagnosed as anyone else.
We are seeing that sort of pressure on rural areas, for example,
on non-inner city areas because of health-seeking demands. There
is no doubt that the new health campaign which is coming on-stream
I gather next week is going to exacerbate that situation.
Sandra Gidley
619. Now something slightly different. We have
concentrated so far on STIs which according to our brief affects
about ten per cent of the population. Sexual dysfunction actually
affects a greater proportion of the population but attracts very
little attention in the Sexual Health Strategy. Would anybody
like to hazard a guess as to why they think that is?
(Dr Munday) I think sexual dysfunction in its widest
sense is very closely linked to all the issues around sexual health.
Many of the reasons why people acquire sexually transmitted infections
relate to poor sexual relationships and sexual dysfunction is
one of the many outcomes of poor relationships. One can see it
as part of a sexual malaise within a relationship or within a
community. I think erectile dysfunction, if that is what we are
talking about, is the tip of the iceberg really. There is an enormous
amount of sexual dysfunction which is under the surface and which
we as clinicians in general practice and in GU medicine constantly
see and we see the consequences of that. In women it is much more
tenuous and difficult to identify because it tends to present
with medical organic-type problems whereas in men it tends to
present with pure erectile dysfunction and therefore attracts
attention and is obviously a cost that can be costed in separately
from other things. It is because of the cost which attaches to
erectile dysfunction there has been some anxiety about it. But
it is only a small part of the whole sexual dysfunction agenda
which needs to be looked at, in my view anyway.
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