Examination of Witnesses (Questions 1044-1059)
THURSDAY 23 JANUARY 2003
MS HAZEL
BLEARS MP AND
MR STEPHEN
TWIGG MP
Chairman
1044. Welcome to this session of the Committee.
Can I particularly welcome you, Minister, to your first appearance
before the Committee. We are pleased to see you. Thank you for
your cooperation with this inquiry. Stephen Twigg will be joining
us at half past eleven, so the first hour of the Committee will
be related primarily to Health Department responsibilities. Could
you briefly introduce yourself to the Committee.
(Ms Blears) I am delighted to be here, Chairman. I
am Hazel Blears. I am the Government's Public Health Minister,
and I have responsibility for the implementation of the Sexual
Health and HIV strategy.
1045. Can I begin by saying that the whole question
of sexual health is something that is not frequently raised with
MPs. The whole Committee has been, frankly, shocked and appalled
by some of the evidence that we have received, that is written
evidence, oral evidence and what we have seen when we have been
visiting various parts of the country. Among the evidence we have
received, Sarah Gill, who was a GU physician at Paddington, told
us, and I quote, "I have never seen the extraordinary intensity
of patient numbers as witnessed in the last six months or so.
The Department is like a war zone/A&E. There is a queue of
patients up to 40 deep most mornings." She said, "Nobody
wants to end up in a clap clinic, let alone when you have to wait
up to four hours to discuss your most intimate of problems with
a harassed doctor, who is still worrying about the last patient
hurrying out of the room in a bid to try to relieve the already
heaving waiting room." A doctor in Chester told us that he
had never seen a service become so "demoralised and overwhelmed,
with staff pushed to the limits." We have figures of a huge
increase in workload and diagnoses. Frankly, the whole sexual
health service appears to be a shambles. Would you agree?
(Ms Blears) I would not agree that it is a shambles.
I would agree that for many years the whole field of sexual health
has not been a priority. Some people describe it as a Cinderella
service. People working in the field have felt that, I know, for
very many years. I have had an opportunity to read some of the
evidence that you have taken as a Committee, and I know that you
have been out to visit. I too have been out to visit since I took
responsibility for this area. I have looked at GU clinics in Manchester
Royal Infirmary, in Hope Hospital, I have been up to a one-stop
shop up in Hull, and I have looked at some of the facilities in
London as well, and I have seen for myself the pressure that staff
are operating under. It is absolutely undeniable that we have
had a huge increase in sexually transmitted infections since 1995.
We have also seen a massive rise particularly in chlamydia and
in HIV, and that is absolutely one of the main drivers for why
we now have the first ever sexual health strategy in government.
For me, it is clear why that strategy was needed, why the action
plan is so important, and why the extra funding that we are putting
in place, both in terms of pump priming from central government
but also, even more importantly, the extra funding from primary
care trusts through their mainstream budgets to modernise, improve,
re-engineer and almost re-energise the whole of the sexual health
field, is so important. We have put £5 million into GU services
in this last year, which we do think will make an appreciable
difference in trying to attack some of the waiting times, which
have gone up from an average five- to six-day wait for an appointment
to 12-14 days, and I know it is much worse in some parts of the
country where they are under particular stress. Long waits for
urgent appointments in this particular field not only affect the
patients, but the evidence is that an untreated sexual infection
can lead to the infection of between one and four other partners
whilst a person is waiting for treatment, so there is a real public
health imperative here as well. I entirely acknowledge the pressures
that people are under, but we are on the case, and that is a very
real reason for the strategy and making sure the strategy works
in practice, on the ground.
1046. The Department, way back in 1988, had
the Monks Report, which you are probably aware of, which recommended
that patients should be seen on the day that they present, or
on the next occasion that the clinic is open. We went to Manchester
and took evidence in your own part of the world—as you know,
because I told you about the visit—and we were told there
that waits of up to six or eight weeks were not uncommon. What
is very apparent is that during this period of time people who
are aware they have a problem continue to have sex. The reason
we perhaps have this shocking and worrying increase in STIs and
STDs is a consequence of people who try to access help being effectively
turned away. I accept that the Government has developed a strategy,
but this problem is surely so urgent that a strategy that is looking
at a ten-year programme is all well and good and is going in the
right direction, and we would all accept that, but it is not enough.
These professionals are frankly crying out for help, and they
are not getting that help. They do not see any future, so we have
difficulties with recruitment. Do you not feel there is a need
to act much more urgently than apparently has been the case in
recent times?
(Ms Blears) I think it is like other
issues that we are facing in the Health Service. There needs to
be almost a twin-track approach: there needs to be urgent, immediate
action to deal with the problems that are facing us today, but
there also need to be long-term strategies for the whole of the
Service. This strategy, like the NHS Plan, is a 10-year strategy,
and I think that is right, because there are two drivers here.
One is about immediate access to services, to get treatment, to
stop re-infection, to stop infection spreading more widely throughout
the community, but the other issue that we all struggle with is
changing people's behaviour. I think you have had evidence from
the lifestyle surveys that people are having more partners, they
are having more concurrent partners, and that people's sexual
behaviour in the last couple of decades has changed quite markedly.
Even though there is an increase in condom use, that is counteracted
by the increase in partners and in the number of concurrent partners.
We have a real lifestyle issue here, and changing behaviour is
a more long-term challenge than immediate services. I entirely
agree; we need to do both; it is not either/or. It is about getting
the money in to release the pressure on those services, to get
waiting times down, but it is also about having that long-term
campaign. A third thing I would throw into the pot is that these
services have not had the attention that they have deserved in
the past. Many of them are still stuck in the clinic at the back
of the hospital, without the kind of profile or importance in
the rest of the service, and bringing that service into the 21st
century in terms of much more primary care is important. In the
strategy we set out a level one, two and three hierarchy of services,
and we envisage many more of certain of the level one services—the
diagnosis, the interview, the partner chase, all of that—to
be done in the primary care setting. That, I feel, will also help
to address some of the work force issues, because in the past
there has been a tradition that everything has happened in hospital
and everything has happened under the aegis of consultants. Consultants
are important in this field, but equally so are nurses, health
care assistants and health advisers. Getting that skill mix in
there and changing the work force, again, is not a matter that
can be done overnight. Right across the Health Service we are
working with the work force confederations to get that skill mix,
to get much more nurse-led clinics, much more nurse-led activity
here, and trying to recruit people into the field. But again,
you only recruit people into the field if they feel it is an exciting
and worthwhile place to have their career. There are a number
of steps we can take: immediate action, injection of funds to
get the waiting lists down, recruiting more consultants, which
we are doing, getting the skill mix in for the nurses, and then
doing the long-term behaviour change work, which we are doing
with our communications campaigns and with our information out
there in the community, and finally, working, absolutely crucially,
with the voluntary sector in this field. You will have found out
from your evidence that it is not just the NHS, but those voluntary
organisations which are fundamentally important to us.
1047. One of the difficulties about your role
in government is that, although you are a Health Minister, your
remit is far beyond the role of the Department of Health. It goes
right across government. I made the point at the outset that I
think some of us have been shocked by what we have picked up.
One of the problems is that politicians are not aware of the extent
of difficulties. I do not use the word "crisis" lightly,
but I think we have a crisis in this area of policy, from what
we have seen and the evidence that we have taken. Do you feel
that there is sufficient awareness across government, cross-departmentally,
among other departments which have a role to play, of the seriousness
of the situation that we are facing in this area of health at
the present time? There are many wider issues that relate to this,
not least the media presentation of sex to young people and children,
and there is certainly the sex education issue, which we will
talk about. Do you feel there is sufficient awareness of the urgency
of dealing with this across government, and at the very top levels
in government?
(Ms Blears) You raise a very important point in relation
to many of the areas that I deal with, whether it is health inequality,
trying to get every government department on board to address
these issues. Similarly with alcohol. I am currently the minister
responsible for the Government's alcohol project, and again, with
DCMS, Home Office, everybody else has a role to play. I know that
in drawing up this sexual health strategy those departments were
fully engaged in realising just how important this issue is to
all of us. This is an issue about our communities, about society,
about behaviour, and it is about the future of young people as
well. Therefore, the Department of Health has played a big role
in the sexual relationships education field. That is something
new for me, that the Department of Health would have a big input
into making sure that that sex and relationships education was
well-founded, evidence-based, good, accurate, credible information,
and therefore I am working very closely with my colleagues across
government to make sure that this issue, as with other public
health issues, impinges on all of our policy responsibilities.
I think increasingly in government we are recognising the cross-cutting
nature of the policy issues that we are addressing. They do not
fit neatly into departmental responsibilities, and it is incumbent
on us, as politicians, to get out of our silos and recognise that
these are issues for all of our communities. I genuinely do think
there is an acknowledgement and recognition of the fundamental
importance of sexual health and these other issues that particularly
affect young people and how important they are.
Mr Burns
1048. Minister, you gave a very comprehensive
review to the Chairman, and you came up with some ideas for the
future of what must happen, with more staff, greater concentration
of effort, greater coordination, etc. I wanted to go back to the
specifics. Being the MP for Salford, of course, you will be familiar
with what is going on in your own area of Manchester. As the Chairman
mentioned, the ideal is for an individual to see a doctor or relevant
medical practitioner on the day that they present themselves,
or if that is physically not possible, on the next day that the
clinic or outlet is open. The evidence is that it is possibly
six weeks, which is 41 days, later. I assume that you were aware
of those statistics for Manchester? You nod, so I take that as
an affirmative. What have you been doing since learning of that
to find out what is going on in Manchester, and what can specifically
be done to improve the situation for potential patients in Manchester,
who ought not to have to wait 41-42 days to see someone, but who
ought to have the service that the guidelines suggest they should,
ie the day they present themselves or the next day that the clinic
is open?
(Ms Blears) In my original answer I acknowledged that
average waiting times had gone up from five to six days to 12-14
days, but in parts of the country, including places like Manchester,
they are much longer than that, and therefore it is a priority
to try and get them down. I think that requires a number of different
kinds of action, which have already started to be implemented.
The first one is the immediate injection of extra cash, and that
is why we put the £5 million in immediately to try and ease
the pressure.
1049. Is the £5 million for Manchester
or nationwide?
(Ms Blears) That was nationwide, from central funds.
1050. In what way will Manchester benefit from
that?
(Ms Blears) I do not have the precise figure for Manchester,
but it was allocated on the basis of the prevalence in those areas,
so it was allocated to those areas where the pressure was the
greatest. I can certainly supply the Committee with the breakdown
of those areas. That was an immediate injection of cash. The second
thing is that we wanted to make sure that every primary care trust
allocated somebody to be responsible for sexual health, because
that has not been the case in the past. We now have 286 PCTs who
have designated a particular sexual health lead. We have 18 outstanding,
and we are chasing them to make sure that we get them, so that
somebody at primary care trust level has personal responsibility
for monitoring the situation and recommending improvements. In
places like Manchester, which do have significant pressure, the
need to redesign the service is even more pressing than in places
which are not operating under that pressure, and therefore getting
more primary care clinics, getting more nurse-led operations,
and also new technology will be important. I went to Manchester
Royal Infirmary to look at their clinic, and I think one of the
problems they were struggling with was that they did not have
a computer system that enabled them to track the contacts of the
people that had come in for diagnosis. Clearly, that is a key
issue in order to reduce the spread of infection. I cannot dictate
to the primary care trusts what their priorities should be, but
from my visit, introducing new technology—or even relatively
old technology—so people can get computerised systems would
be a top priority for me.
1051. Is there not going to be a problem there,
despite the best intentions of the Health Service or politicians,
in that a proportion of patients will possibly not actually give
their name or accurate address? Because of the nature of their
medical condition they do not actually want to be contacted. They
want the treatment, not unreasonably, but they do not want follow-up
contact, except by them presenting themselves at the clinic.
(Ms Blears) I think that will always be an issue in
the area of sexual health. Confidentiality is absolutely fundamental
to people trusting the system, that they know they can get treatment
and they are not going to be unduly exposed to their friends,
their neighbours, their community, and that trust is very important.
Obviously, there are protocols in place for confidentiality, about
access to information. There I think the role of the health care
adviser is crucial, because that is somebody who perhaps can take
the time, whereas consultant will be heavily pressed to get the
patients through. If you have a health care adviser, they can
sit down with somebody and talk it through, talk through the implications,
and maybe explain some of the public health issues to people.
My experience is that if these issues are properly talked through
and reassurance given, people are much more likely to want to
cooperate and give us that vital tracing information so that we
can get other people treated. I am not saying for one moment that
we will get 100% accurate information, but the more we can do
to maximise it, the better for the whole community.
Chairman
1052. When you went to Manchester, which, as
you know, the Committee have been to, to the Royal Infirmary,
I seem to recall being very struck by the fact that in the examination
rooms the doctors do not even have sinks to wash their hands.
Did you notice that?
(Ms Blears) I did not notice that personally. I went
on a very brief visit. It was at the end of a day of presentations
from the consultants to me, so it was a relatively brief visit,
but I was not aware of that.
1053. One of the worries we have is the facilities
we have seen. We are going to the West country, where we understand
some of the problems are even worse than in Manchester. The physical
facilities are, frankly, below what could be described even as
basic. To conduct an examination of the kind that would be conducted
when there is not even a sink in the examination room, I find
frankly amazing.
(Ms Blears) Can I just comment on that? I think that
is right. In some parts of the country, because it has been a
Cinderella service, and stuck at the back of the hospital, that
is the case, but when I went to visit Hull, and looked at their
new facility, which is a one-stop shop, where we are currently
calling for pilots to take place, they have a range of community
facilities: a drop-in clinic, so people can just turn up; it is
right in the centre of town, so it is very accessible; and they
have a multidisciplinary team working together there, sharing
ideas. That is the other end of the spectrum, where there has
been significant investment and it is a good service. Perhaps
that gives a flavour of the variation that there is in services
across the country.
John Austin
1054. On the one-stop shop, what is the timetable
for the evaluation of its effectiveness?
(Ms Blears) At the moment we are just calling for
bids for the models. The one in Hull has gone ahead on its own
initiative. Nationally, we are right at the beginning of that
process in terms of looking at the models that we want, and I
am not sure if Hull are undergoing their own evaluation, or if
that is simply a policy they have adopted as a local community.
I can certainly let you have the timetable for the evaluation
of the different models that we want to test out for a more community-based
kind of service.
Dr Taylor
1055. I wanted to pick up two things you said,
Minister. PCT leads: in counties where PCTs have joined together
to commission sexual health services, does each of the PCTs still
have a lead, or do they count the lead in the commissioning PCT
as the lead for the whole area?
(Ms Blears) As far as I am aware, we have asked each
PCT to nominate a lead person, and I think that is important,
because they are commissioning for their residents. But obviously
we have consortia arrangements, particularly for specialised services,
for example, for HIV services, which can be very specialised,
and it is important that PCTs come together. But I would expect
somebody in each PCT to take personal responsibility for developing
services in their community, because some of the services are
very community-based: contraceptive services really should be
all over. So you have a hierarchy of services in sexual health,
some very specialised, some fairly straightforward, and there
ought to be somebody in each PCT with responsibility for that.
1056. Going back to waiting times, we have heard
in several places that they have found an answer, because if people
were waiting for six weeks, or even four weeks, the number that
did not attend, the DNAs, was very high. So they have organised
a system where the clients ring up literally the day before the
clinic and that clinic is full after half an hour, but to my amazement,
when we talked to young people last week, they welcomed that sort
of arrangement. Is this something that you would push nationally?
Have you a view on this?
(Ms Blears) I have talked to some of the practitioners
who have been developing similar schemes, whereby they ring people
up the day before and slot them in or try and make arrangements
in that way, and I think we have a lot to learn from different
examples of good practice across the country. One of the things
the NHS struggles with is spreading that good practice, as I am
sure every, single one of you has experienced, and therefore perhaps
having a system where in developing the strategy, we can learn
from that good practice, because again, because of the confidentiality
issues as raised by Mr Burns, it can be that we have a large number
of appointments that are not kept. We have a lot to learn from
those examples of good practice, yes.
Sandra Gidley
1057. You mentioned Hull, which is bright, shiny
and new and what we all ought to aspire to, but that is a one-off.
I know you have read some of the evidence, but I do not know if
you are aware of a statement made by Dr Kinghorn, who said that
their society had done a survey in April 2001 and reviewed all
the clinics within England, and I quote: "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% of clinics,
and there would be the problem of space. About 20% are Portacabins
and worse. Some of them have been in the Health Service for many
years, even decades." Is that really good enough?
(Ms Blears) I do not think it is good enough. The
very reason that we have the strategy, the very reason that this
important inquiry is taking place is because sexual health services
have not been a priority for many, many years. I think that would
be all of our personal and professional experience, and therefore
there is a need to not just invest in physical facilities, although
that is very important, but also to give the whole profession
the sense that this is a very important area for people to be
operating in. I entirely acknowledge that we have a long way to
go, but for us to be saying from the centre that by having a strategy,
this is a priority for Government, the first ever; by having an
action plan, there is a focus on it; by saying you have to have
a PCT lead in every single community, that makes it an important
thing for the Health Service to do. I should think that many of
the clinicians and many of the people who work tirelessly, day
in, day out, sometimes thanklessly in this area, would be pleased
that at long last there is a focus on their area, which means
that when they are battling for funds locally, they can point
to the fact that the Government thinks this is a priority.
1058. Would you like to bet on when this will
improve, and when we will have only 20% needing refurbishment?
Would you like to give us a date?
(Ms Blears) I am not a betting person, but what I
can say is, like the rest of the NHS, we have done a lot, there
is a long way to go, but I think things are moving in the right
direction. In sexual health too over the next few years—it
is a 10-year strategy—we will see significant improvements
in the physical fabric. We have to remember, we have the biggest
hospital building programme that we have ever known in the NHS,
and it is not just hospitals but primary care centres and one-stop
shops that are going up now in communities. Sexual health, like
the rest of the National Health Service, has an important role
to play, and should have its place in some of those new facilities.
1059. I wish I shared your optimism, Minister.
If I can just pick you up on one other thing you said, you commented
that what could happen in clinics, or maybe what did happen, was
that there were people there who could spend time discussing lifestyle
issues and all the rest of it. My experience when I spoke to people
in Manchester and speaking to other professionals was that even
those people were rushed and did not have the time to do that
job properly, and there was a feeling that they were taking a
sticking plaster approach, sorting out the problem, and sending
people away without the information you are describing. What are
you going to do to ensure that that part of the service really
does happen and it is not as squeezed as the rest of it?
(Ms Blears) I think it has to be acknowledged that
those services are just as important as the medical service that
is provided, that this is a proper balance, and that this is not
just a medical problem. It is about lifestyle, it is about contacts,
it is about tracing and it is about behaviour. That brings me
back to the skill mix issues, having more nurse-led clinics, where
people do operate in a different way, where they do have time
to sit down and talk through these issues. Already quite a lot
of information is given out in my experience: health promotion
literature, advice on lifestyle, advice on how to prevent sexually
transmitted infections. I would not underestimate the amount of
health promotion work that does go on. I acknowledge the pressures
that there are on staff, but my experience is that people do engage
in this kind of discussion, and yes, we need more capacity in
the sector, as we need more capacity right across the NHS, and
that is why, over the next three years, the PCTs are getting a
significant increase in funding, and we are saying that our central
funding, the £47.5 million, is really pump priming, and we
expect significant investment to be made at PCT level in making
all of these services improve.
|
