Examination of Witnesses (Questions 1060-1079)
THURSDAY 23 JANUARY 2003
MS HAZEL
BLEARS MP AND
MR STEPHEN
TWIGG MP
John Austin
1060. We have talked about Manchester, which
may be set down as an extreme example and, like the problems in
Brighton and parts of London, attributable partly to the significant
increase in syphilis, but the general evidence across the country
is that in one-third of areas there is a wait of three weeks or
more. Do you anticipate that the average waiting times will come
down by the end of the y ear, and if not, what will your assessment
be?
(Ms Blears) I think I would be disappointed if we
did not see some of the very long waiting times begin to come
down as a result of the immediate injection of the £5 million,
because I do think that that ought to go some way to reducing
some of those more extreme pressures. But as I said before, this
is a long-term strategy as well, and if you look at some of the
figures, the way in which the sexually transmitted infections
have been going up astronomically since 1995, this is a problem
for all of us in society. If we stayed static, I would hope to
see the £5 million make a real impact on those waiting lists,
but equally if the figures started to go up exponentially again,
we would be coping with yet another increase. I am a little reassured
in that the rate of increase of sexually transmitted infections
appears to be slowing down in the very latest figures that we
have for this year. Those are the 2001 figures. We do not yet
have the 2002 figures. But the rate of increase appears to be
slowing down, so in those circumstances, I would hope that the
immediate injection of cash would have a fairly significant effect,
but that immediate injection of cash has to be linked with investment
from the PCTs starting to come on stream, so that we can begin
to see a bigger investment at local level as well. We are going
to develop a waiting times indicator that we will be able to monitor,
so I would be able to provide some further information when we
see the effect of that investment on those waiting times. We are
determined to monitor this, because in public health terms, as
I say, it has quite a dramatic impact.
1061. Is that £5 million injection of cash
within the £47.5 million or is that additional to it?
(Ms Blears) No, that is within the £47.5 million.
If I can give you the figures, in the first year of the strategy,
2000-01, it was £5.5 million; in 2001-02 £14 million.
No, that is 2002-03. In the next year I think £28 million,
which comes to the £47.5 million all together.
1062. The £47.5 million is for the first
two years of the 10-year strategy?
(Ms Blears) Yes. It is the three years. That is what
was promised when we launched the strategy, that it would be backed
by £47.5 million.
1063. You are aware presumably that in the evidence
we have had from those working in the field this is regarded as
paltry and, one witness said, was perceived with ridicule. How
would you react to that?
(Ms Blears) I would be disappointed if it was received
with ridicule, because I think it has been well thought through,
and it is the case that this is central money, designed to pump
prime change, to act as a catalyst for redesigning services, to
go into places, to do some pilots, to look at different ways of
operating, and when they prove their worth, to have those pilots
picked up by mainstream funding. I think that is a proper role
for central pots of money. I do not think it is proper for central
money to run local services for ever and a day, and the whole
thrust of shifting the balance of power is to get the NHS's budget
out at the front line with the PCTS so that they are making commissioning
decisions in the interests of their communities. I think a good
role for central government pots is to bring together the good
practice, as Dr Taylor has talked about, and then say, "How
can we drive that across the service?" If people are under
the impression that this £47.5 million is all there is, then
I would sympathise with their view, but this is about unlocking
and releasing some of the extra funds that we have put down through
the service by the biggest increase we have ever known.
1064. I would certainly welcome the strategy
and the emphasis that you put on it. I think most of us would
recognise that the problems that we face are both in increasing
incidence and what you refer to as a historic under-funding of
the service. Whatever the Government may do—and you say
this is pump-priming money—you have referred to the historic
under-funding and set out some of the reasons why that under-funding
may have existed. What has changed, in your view, which will ensure
that those previous pressures that have led to an under-funding
of this service do not continue and this does receive the priority
and at a local level that perhaps you and I would like it to receive?
(Ms Blears) There are a number of things that we are
developing and putting in place which will, I hope, make this
an important issue for primary care trusts to take into account
when they are planning their spending. There is, first of all,
the fact that we have asked for a person to be identified, so
there is somebody that everybody can look to whose job it is to
make this happen in communities. Secondly, we are developing some
much more detailed monitoring through the AIDS Control Act, in
terms of spending around HIV prevention and treatment, because
again, I think there was a real worry in the HIV sector that when
we removed ring-fencing, the money would somehow disappear.
1065. There still is.
(Ms Blears) Indeed. I think I can tell the Committee
that we have done a brief survey, a sample of a range of authorities,
urban and rural, in terms of the money that has been invested
in HIV work, both prevention and treatment, and certainly the
information from that sample survey is that people have kept up
to the levels that they were funding, and in some cases have actually
spent a little bit more, so we are reassured to some extent by
that. But we are developing a monitoring system through the AIDS
Control Act which will give us more detail about where the money
is actually being spent, and importantly, rather than just the
money, we will be concentrating on the outcomes to see what difference
it has made to patients and to communities, because sometimes
it is quite easy just to put the figure in and say, "Yes,
we spent that," but it is important for government to be
able to see how it was spent and what effect it had. I think it
is important to develop those issues too. The third thing I would
say is that sexual health is certainly included in the Inequalities
Framework, in the Planning and Priorities Framework, for the NHS,
and there is nothing more important to the Government than tackling
health inequalities, and therefore that again will aid people
at local level to make this an important area of work by saying
that it contributes to our push on inequalities. If you look at
the distribution of sexual health services, and the people who
suffer most from sexual diseases and problems, it tends to be
young people, many people in black and ethnic minority communities,
where rates of gonorrhea and other sexually transmitted infections
are much, much higher, and their services in some cases are much
poorer. So in terms of the Inequalities Framework, there will
be a real drive on sexual health as well.
John Austin: We may come on to the question
of the removal of ring-fencing later, because I think what you
have said is not in line with the evidence we have from, say,
Terrence Higgins, but perhaps we can address that later.
Chairman
1066. Minister, you talked about looking at
the impact of additional investment, the strategy, and how the
investment is affecting this area of policy. Looking at it the
other way round, one of the things that you can frequently see
in health policy is that if you invest a small amount of money
now, it saves you a much bigger sum of money later on. Have you
within the Department done any calculations on the way the lack
of resourcing of this area is leading to the inability to treat
people and consequent further infection and consequent more costly
treatment at the time the individual actually gets treatment?
HIV is probably the best example, but it is the case with other
problems as well that if you leave it longer, it costs you more.
Is that a calculation that you have done? It is certainly something
that we have picked up in evidence that is very worrying.
(Ms Blears) I am not aware of any specific calculations
on that.
1067. Would you accept the general argument?
(Ms Blears) Right across the range of clinical conditions,
early diagnosis, screening, early effective treatment is important,
and as Public Health Minister, I absolutely fervently believe
that investment in prevention is a good investment for the whole
of the Health Service.
1068. Yes, but the point I am making is that
with this in particular, it is not just one person that is suffering;
it is others who are also suffering as a consequence of the lack
of treatment of the first person, who is turned away.
(Ms Blears) Indeed. What I would point to is that
the development of the chlamydia screening pilots—and I
am sure Members will want to press me on those issues—is
an example of how much we do recognise that, that being able to
identify people at an early stage, and get relatively simple treatment,
for example for chlamydia, where we can clear up the infection
in a pretty straightforward way, not only is good for the individual,
but it also saves us the money later on in terms of the really
serious effects of chlamydia, ectopic pregnancy, etc. That would
be a very, very good use of our funds. We are already beginning
to think in that way. I have a couple of figures here which might
be helpful, that the prevention of unplanned pregnancy by contraception
services probably saves the NHS over £2.5 billion a year;
the average lifetime cost for an HIV positive individual is calculated
to be between £135,000 and £181,000, and there have
been some estimates that preventing a single transmission of HIV
could save us between half a million and a million pounds, which
is a stunning figure, and I think illustrates the important point
that you are making.
Chairman: It just strikes me that if you were,
as you do, bargaining with the Treasury about your future budgets,
you have some pretty strong evidence here that some additional
investment would save the Treasury a lot of money in the long
term.
Dr Taylor
1069. Can we move on to consultants? I know
you have talked about skill mix, and I am sure we all welcome
extension of nursing duties and other professionals and the part
they can play, but specifically asking about consultants, in some
of the places we have been to the ratio has been 1:300,000, in
my own county it is 1:270,000, yet the Royal College of Physicians
recommends a figure of 1:119,000. Do you think that is realistic?
Do you think they are in a bargaining position, aiming at a very
good figure and hoping for something better? What is your view
about the level that we should have?
(Ms Blears) Obviously, we need to get more consultants
in the specialty, as we do right across the board for consultants.
We have commitments and plans to do that. I understand that we
are likely over the next two years to get an increase of 35 consultants
in this field. At the moment there are 275 consultants operating
here, and so an increase of 35 is a significant increase, and
that is a net increase, having taken into account retirements
as well.
1070. Does that take into consideration the
SPRs in training? We gather there are far more SPRs in training
than there are jobs available. Will that match that number?
(Ms Blears) I am not aware of the detail on that matter,
Dr Taylor. My information is that the plan is to get 35 extra
consultants into the field, and I think there are a number of
extra Specialist Registrars as well coming on stream for us. So
there is a significant increase in this field.
Dr Taylor: I think there is something like 30
SPRs each year achieving their training.
Julia Drown: There is an output of consultants
of about 30 a year, but we also have around 70 doctors that complete
specialist training in GU medicine in this year, 2002-03.
Dr Taylor
1071. So it looks as if there are more who are
going to complete training than there are going to be jobs for,
which deserves looking into, at any rate.
(Ms Blears) As far as I am aware, there are ongoing
discussions with the Royal College of Physicians about making
sure that we have enough consultants in this specialty, that we
are training enough consultants, and clearly that there will be
sufficient roles for them to undertake. I know this issue is being
discussed by the National Workforce Development Board, the workforce
people who are out there, together with the College, and it is
important if people want to go into this field, who have a real
enthusiasm for it—because it is one of those areas where
you do need a real commitment to work—that we make the most
of their skills. I am not aware—certainly it has not been
raised with me—of the possibility of more people training
than there are going to be jobs for. It is almost the reverse;
we do need more consultants working in this field, together with
more nurses and more health care assistants.
1072. The other figures we have been given are
that 25 consultants in the specialty are still single-handed,
which is fearfully difficult, and that something like 30 per cent
of the clinics only manage for three days or less in the week.
(Ms Blears) Can I comment on the single-handed consultants,
because I think it is an important point? It is not good for anybody
to be working in isolation. It is not good for them, and it is
not good for the patients, and therefore we are really concerned
to try and set up some clinical networks so that some of the consultants
can work more closely together, learn from each other, make sure
their training is right up to date, and give each other some support
in the way that they are working as well. So it is quite a priority
to get those clinical networks in place for the single-handed
consultants.
1073. We have seen some of those. Did you say
a commitment to 35 new consultants?
(Ms Blears) Yes.
1074. Where is the funding coming from for those
posts?
(Ms Blears) As I say, the funding that we have put
into the GU service is the —
1075. So it is money that is already supposed
to be in the service? Is it out of the £47.5 million?
(Ms Blears) Those new consultants who are coming through
by 2004 will already be in training and will already be funded.
1076. So the money is there?
(Ms Blears) Yes. That is my understanding.
Chairman
1077. If you find out that is not the case,
perhaps you will drop us a line.
(Ms Blears) I will get back to you immediately. I
would not want anything on the record that was not absolutely
correct. That is my understanding. They are coming through by
2004, so that is imminent.
Julia Drown
1078. You spoke a while ago about the costs
you can save by preventing just one HIV case. Has the Department
a view on the campaign by the Safer Needles network that say that
if all NHS trusts actually used safer needles, you would prevent
needle-stick injuries, and therefore the huge worry of staff when
they might have picked up HIV, and also, obviously, if the case
occurs in the NHS, the extra cost to the NHS and also the effect
on morale of that member of staff and everyone around? Has the
Department looked at that to consider whether there should be
yet another central directive to say that all trusts should be
using safer needles? Some trusts in the country are, but only
a very small proportion.
(Ms Blears) I personally have not seen anything in
terms of guidance that we would be considering issuing at the
moment, but I think it is a very important issue that you have
raised, because the safety of staff and, as you say, their morale,
and the fact that the NHS should be looking after them as much
as looking after the patients, is very important. Perhaps it is
something that I could undertake to raise with officials and to
look at myself.
1079. Moving on to chlamydia, you have spoken
about the pilots that have been going on in the country. One of
the issues that we have discussed in looking at those was about
the different diagnostic tests that are used, and we are disturbed
to hear that the most commonly used test, which is this EIA test,
has a sensitivity of only 50-75%, which we have been told means
it misses about 30% of the women and nearly half of men. That
compares to the more expensive PCR test, which has a sensitivity
of at least 95%, but we understand only about 10% of clinics are
using the most expensive test. What was even more shocking for
us as a Committee was to hear that when at least one of the pilots
stopped being a pilot, they moved from using the better test back
to the old test. Is the Government going to take steps to ensure
that the better test is used? Surely it is the most efficient
method to make sure the PCR test is standard.
(Ms Blears) The very reason that we have these pilots—and
we started the first two in Wirral and Portsmouth and we are now
extending to a further eight sites, so there are 10, including
those two pilots—is for us to be able to explore different
ways of operating, what kind of training we need, what kind of
tests we can do, what is the most successful setting, what are
the best follow-ups, all of those things that you really only
find out from actually doing the work rather than designing a
framework sat back in the office. I think it is absolutely vital
that we look at all of the evidence about what works, what is
the most effective, and clearly we will be looking at cost and
value implications as well, because that is a relevant consideration
for the NHS in how we spend our money. I can certainly give a
commitment that we will look at the evidence from those pilots
about the different effectiveness of those tests. Something was
brought to my attention that the urine tests are very acceptable
to the patient because they are a non-invasive test, and yet I
am told that the self-swab, which is invasive but you actually
do it yourself, is much more accurate and still very acceptable
to the patient. So exploring those different models of tests I
think is very important.
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