House of Commons - Health

Select Committee on Health Third Report

6 TREATMENT AND SERVICE PROVISION

84. Sexual health care is provided in many parts of the NHS including general practice and family planning. Since 1917 specialist services have been established for the management of sexually transmitted infections.[57] In the UK, a network of over 250 GUM clinics, led by consultant physicians, deals with the clinical management of STIs; most of the HIV seen within the UK is managed within departments of GU medicine.[58] These are normally attached to main hospitals. Patients can attend a clinic anywhere in the country. GUM clinics not only handle the treatment of conditions but are also instrumental in notifying the partners of those affected, using specially trained health advisers, and have some responsibility for recording epidemiological data on particular diseases.

STI services

Consultant numbers

85. Consultants in GUM undertake an initial training in general medicine and gynaecology before four years of specialist training.[59] According to the latest Royal College of Physicians (RCP) survey, there are around 238 whole time equivalent GUM consultants in England.[60] Dr Janet Wilson, Chair of the Specialist Advisory Committee in Genito-urinary Medicine and a GUM consultant at Leeds General Hospital suggested that not enough consultant posts were being created for the specialists who were being trained, a point echoed in our visit to Manchester.[61] Dr George Kinghorn, immediate past president of the Medical Society for the Study of Venereal Disease, and a GUM consultant in Sheffield, told us that there were currently about 120 specialist registrars in training and that their training period was around four years, giving an output of consultants of about 30 per year.[62] He thought that to get up to the figure of one consultant per 119,000 population, the ratio recommended by the RCP, would require an extra 173 consultants for England.

86. Evidence submitted to us points to numerous parts of the country where the consultant: population ratio falls well below the RCP guidelines. In addition, there are many locations, even outside rural areas, where services are scant or non-existent. GUM consultants in North Cheshire told us of a ratio of 1:325,000 in the North Cheshire/Wirral area.[63] The figure of 1:300,000 is cited in South Buckinghamshire.[64] Dr Helen Lacy, a GUM consultant in the North West claimed that a ratio of 1:400,000 prevailed in her area.[65] The Head of the GUM service at Newcastle General Hospital told us that there was no GUM service in all Northumberland and Gateshead.[66] Dr Mark Fitzgerald described himself as a single-handed consultant covering the whole of Somerset from two clinics.[67]

87. There clearly are shortages of trained staff but some caution may be required here. The shortages in GUM consultants identified by the RCP form only part of a pattern of a general dearth in consultants. The percentage shortfalls for several other specialties are much higher: while a 96% increase is needed in GUM medicine to bring it up to the recommended ratio, an increase of 265% is sought in clinical neurophysiology, of 306% in rehabilitation medicine and of 812% in audiological medicine. Further, the estimates of what were needed were supplied to the RCP by the specialties themselves.[68]

88. We put this point to Dr Kinghorn. He told us that, so far as he was aware, the RCP's estimates of what was an acceptable ratio of consultants to the population were not in dispute. Moreover, in weighing up the competing claims of GUM against, for example, neurology in arguing for an increase in numbers, Dr Kinghorn suggested his patients had an infectious disease which they could pass on to others; there was a "public health imperative".[69] The Department would appear to have accepted the claims of GU medicine, given the increase it has made in the number of those now in training.[70] The Public Health Minister, Hazel Blears MP, told us that there would be a net increase of 35 Specialist Registrars qualified to be consultants in the next two years. However, staffing figures from the RCP indicate that no consultant jobs currently exist for these 35 specialist registrars, who have completed their training.

89. The Department itself has no direct control over the creation of posts which is a matter for determination within local health economies, where the need for additional posts in one area has to be weighed up in the context of many competing demands. But as our visit to Bristol made clear, when we met the Trust Chair and Acting Chief Executive, sexual health is not a first priority for trusts: waiting times for other specialties was cited as the key priority. On our visit to Manchester we were told that there would be no new posts for newly qualified consultants and that in fact they had recently lost a post. Dr Pat Munday, a GUM physician in Watford, described what had happened in her clinic. In January 2001 year on year attendances had increased by 35%; evening sessions were "overwhelmed" and staff demoralised. A bid for a new consultant was rejected, an outreach service was abandoned and clinic closures, on an ad hoc basis, were introduced. Trusts were prioritising other service areas and it was suggested that the sexual health budget should be cut by £200,000.[71] We were shocked that such an obvious public health priority is being accorded so low a priority.

90. We are concerned that there are not enough available consultant posts to be filled by appropriately trained specialist registrars. Given the shortfall of 90% in consultant numbers as against the recommendations of the Royal College of Physicians, the increase in workload and the problems of access, this is unsustainable. We recommend that the Government urgently review the staffing requirements and the need for an expansion of consultant posts in GUM. We also recommend that the Government makes clear that the additional money granted to GUM services will be given on a recurrent basis so as to encourage the creation of additional posts.

91. It is not easy for us to judge how much recurrent funding would be needed to have a real impact on the numbers. However, we note the estimates submitted by Dr Kinghorn that, given an average cost for a completed new patient episode of £150-200, and assuming an additional 150,000 episodes per annum (allowing for increases prompted by the Government's publicity campaign) an additional revenue commitment of £22-30 million per annum will be required.[72] While any increase in funding needs to be fully justified and accounted for, in the context of the current disastrous impact on public health of the nation's poor sexual health, these figures do not strike us as excessive. It should be stressed that there is not just a shortage of consultants: nurses with expertise and training in this area, health advisers and laboratory technicians are all needed and these should not be left behind in any increase in funding, a point we develop below.

92. There has been evidence that money intended for HIV treatment, but not ring-fenced, has sometimes been diverted, so we would like the mechanisms to be in place to ensure that any additional funding that is granted to specialist GUM/HIV services is allocated specifically to these services.

93. The Specialty Societies for Genito-urinary Medicine pointed out that around one third of consultants currently operate in single-handed practices which is unsatisfactory in terms of clinical governance. Single-handed practice also places unreasonable demands on staff or patients in terms of taking holiday leave or having the opportunity to pursue further training; finally it limits the amount of training and continuous professional development which can take place.

94. The Minister acknowledged that the high proportion of single-handed consultants in this area was a concern. She told us that the Department was trying to set up some clinical networks so that consultants could co-operate more closely, support training initiatives and generally help one another. This is a policy also outlined in the Strategy.

95. It is far from ideal for services to be managed by single-handed consultants. It is difficult for single-handed consultants to find a consultant locum to cover holidays and study leave. At this point we would accept that it will not be possible for every clinic to have more than one whole time equivalent consultant. However, more than one consultant can provide the service within each clinic so long as there are shared consultant appointments within clinical networks.

ACCESS TO, AND PRESSURES ON, SERVICES

96. Shortages of consultants, and the rapid recent escalation of infections, have led to very considerable pressures on existing services. Between 1991 and 2001, new episodes seen at GUM clinics in England, Wales and Northern Ireland rose from 669,291 to 1,332,910. Clinic workload increased by 155% and diagnoses by 61%. Between 2000 and 2001 alone the figure for episodes at clinics rose by over 10%. As well as a rise in numbers, as Dr Kinghorn pointed out, there has been an increase in the complexity of the workload, since GUM is the major provider for HIV treatment and care.[73]

97. The impression from a survey of the memoranda we have received is of a crisis overwhelming the service. Dr Sarah Gill, a GUM physician at Paddington told us: "I have never seen the extraordinary intensity of patient numbers as witnessed in the last six months or so. The Department feels like a war zone or Accident & Emergency; there is a queue of patients up to 40 deep most mornings."[74] As she put it: "nobody wants to end up in the '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 hurried out of the room in a bid to try to relieve the already heaving waiting room." Services at Airedale Hospital in West Yorkshire were described by one clinician as "fallen in to pieces due to lack of resources".[75] For another consultant in Rochdale and Bury, specialist services were "understaffed, under-resourced ... overburdened and demoralised".[76] Dr Jillian Pritchard, a consultant in Chertsey in Surrey said that local services were "swamped".[77] Dr Colm O' Mahoney, a single-handed consultant in Chester reported he had "never seen a service become so demoralized and overwhelmed" with staff pushed to the limits. He drew our attention to the fact that the 300 or so consultants in GUM were totally dedicated to the NHS, with fewer than 4% being engaged in private practice.[78]

98. Until recently many GUM clinics operated a walk-in service. This picture has changed out of recognition and the situation is rapidly deteriorating. A consultant at St Mary's Hospital London, told us that six out of eight GUM clinics in the North West London sector had had to abandon open access in the last 18 months.[79] Dr Beng Goh, the Association for Genito-urinary Medicine representative for the North Thames area, said that clinics with walk-in services were "inundated", which was hardly surprising when some clinics were operating six week waiting times.[80] The PHLS told us that the median waiting time for a first appointment for men in GUM clinics was now 12 days and for women 10 days. The figures as recently as the year 2000 were six and five days respectively. Moreover, some areas have experienced even greater increases in workload. The Courtyard Clinic at St George's Hospital, Tooting suggested it had witnessed a growth in attendances from 22,500 in 1995 to 36,500 in 2001, an increase of 62% in workload:

99. Dr G A McCarthy, a GUM consultant at the Wolverton Centre in Kingston, London, emphasised the scale of the problem: "We only open up the appointments clinic a week in advance but these are usually booked up within an hour of opening." She estimated that about a hundred people a week had to be turned away. In Manchester we were told that waits of up to six or eight weeks were not uncommon and similar figures crop up throughout written evidence.[82] Yet Manchester has had a recent outbreak of syphilis and records high rates of chlamydia, gonorrhea and HIV.

100. In many centres, a system of appointments has had to be abandoned in favour of a service where patients phone in on the morning. We were told that the Archway Clinic in London had now introduced such a system: all of the available male appointments were booked within 15 minutes, and the female ones were booked in half that time.[83] On our visit to Bristol, where a similar system was in place, around 400 patients a week were currently being turned away.

101. The consequences of such long waiting periods in this area are not hard to predict. As the PHLS put it:

102. The Specialty Societies for Genito-urinary Medicine similarly noted a worrying trend, whereby problems of access directly exacerbated the problem: "Many clinics are reporting increases in the number and proportion of complicated cases, consistent with deteriorating access." Persons at increased risk fail to obtain timely treatment and may continue to spread their infection. This is not merely anecdotal evidence. Dr Fenton of the PHLS cited American and British studies which suggested that around 30% of individuals continue to have sexual intercourse despite being symptomatic.[85] This is particularly worrying in areas experiencing sudden outbreaks (for example, the syphilis outbreaks in Greater Manchester, London and Brighton). Dr Fenton gave an example of the potential negative consequences of delays in access to GU, the case of a patient suffering primary syphilis. This person might be put on a waiting list, find that his or her initial sore or chancre spontaneously resolves, and mistakenly believe that he or she is no longer ill.[86] The patient might then choose not to seek further medical intervention, thus facilitating the onset of secondary syphilis.

103. Such delays are also likely to compound health inequalities. As Dr Kinghorn pointed out: "Those who are less articulate, those for whom English is not their first language and those who are young, are likely to have longer delays." Dr Kinghorn also pointed out that delays in access "tend to adversely affect those who are in greatest need, particularly young people, those from ethnic minorities and those from deprived backgrounds."[87] Those who were less articulate or for whom English was not a first language would be less likely to be able to negotiate their way around the system and get seen earlier.[88]

104. The Royal College of Physicians sets out a template for best practice in this area:

Patients suspecting an acute STI should be seen on the day they present to a clinic, or on the next occasion the clinic is open. Most departments hold clinics at least four days per week and should have dedicated premises.

Clinics should be in good quality easily accessible premises. There should be a relaxed atmosphere to assist confidential discussion of sexually related conditions. Interviewing rooms should be sound attenuated and examination rooms should afford privacy.

105. Our evidence suggests that such best practice is currently far from widespread. A consultant in Chesterfield/Sheffield, told us that, in his clinic, unless a patient clearly had an infection they would have to wait up to four weeks. In his opinion patients needed to be seen within two days if the spread of infection was to be controlled.[89] Dr Kinghorn indicated that over a third of clinics were unable to see patients for three weeks or more.[90] He pointed out that General Practitioners were aiming for a target of seeing patients in 48 hours, and felt that the standards for the treatment of a communicable disease ought not to be any less.[91] A Department of Health working party and subsequent report (The Monks Report, 1988) set out a standard of seeing a patient on the day they present or the next day and this was adopted as Government policy in 1990.[92] However, it is now clear that the initial Department of Health target is not being met.

106. Many clinics are now introducing nurse triage or are attempting to triage over the phone. However, as Dr Jillian Pritchard pointed out, triage is difficult since many patients are asymptomatic but could still have an urgent problem.[93] While a number of clinics maintained that they were now making maximum use of nurses to alleviate the burden, the Royal College of Nursing thought that the under-use of nurses represented a real "lost opportunity". Nurses would be well placed to go out into the community and operate outreach schemes. Nurses, in the view of the College, could also be used more in schools to promote good sexual health.[94]

107. Such are the pressures of work that those consultants in place appear to have little time left over for training and development of staff. Jackie Rogers, a lead nurse for sexual health services for two PCTs based in the Hastings area, said that the pressures on clinical time meant that there was no time left for teaching, meetings or clinical networks.[95]

108. The Department told us it was committed to developing a new indicator around waiting times for GUM services.[96] The Public Health Minister said she would be "disappointed" if the additional £5 million allocated to GUM medicine this year did not go some way to relieving these pressures, though she conceded this would be undermined if the figures for infection were to continue to rise dramatically.[97] She cited the development of a waiting times indicator as a means of monitoring the effect of the investment of the new money on waiting times.

109. It seems to us a matter of grave concern that patients in some cases are waiting eight weeks to see a consultant, during which time a substantial proportion will remain sexually active.

110. We welcome the fact that the Department is developing a waiting times indicator as a means of monitoring the effect of its recent investment on access to clinics. However, this will merely duplicate existing activity since the Public Health Laboratory Service and the Specialty Societies for Genito-urinary Medicine already monitor waiting times, and evidence of the extent of the problem is not wanting. So we are unconvinced that this measure alone will do much to address what amounts to a public health crisis. We recommend that there should be a presumption that anyone wishing to access genito-urinary medicine should be able to do so on the day of, or day after, presentation to a clinic. If a target of 48 hours to see a GP is appropriate then a target of 48 hours for the treatment of what is potentially a communicable disease is essential. Without such standards of access the very delays in accessing treatment will inevitably cause further disease and that in turn will contribute to the pressures on services. It is also essential that if clinics do not allow patients to book an appointment more than 48 hours in advance, this does not conceal the problem of patients who are not able to make an appointment.

PREMISES

111. Premises where GUM clinics operate are also frequently a target for criticism in the memoranda. We visited The Milne Centre, a GUM clinic serving Bristol, where services were conducted in a Portacabin condemned as a fire risk. The Wolverton Clinic in Kingston, we are told, lacked sinks in some clinical rooms. Dr K C Mohanty, a consultant in West Yorkshire described the standard of his clinic at the Airedale General as being "less than that of a developing country". Services had actually deteriorated over the last ten years with the withdrawal of a lab technician who used to read test slides.[98] Pressure on departments also jeopardised patients' chances of being seen in appropriate levels of privacy.[99]

112. The Specialty Societies for Genito-urinary Medicine estimated that around 20% of clinics were located in Portacabins and that refurbishments and extensions were needed for about 80% of clinics; the total cost for carrying this work out was estimated to be between £152-248 million, depending on the level of work.[100] This is a consequence of historic under-funding of services. Dr Munday told us that she believed that specialties that used routine outpatients tended to be upgraded every ten years or so but that GUM was outside this system and had to bid separately, giving the potential for neglect.[101]

113. On our visit to the Milne Centre, we were struck by the extent to which the poor quality of the building had a deleterious effect on the ability of staff to work efficiently. Members of staff had constantly to shepherd patients from one end of the building to the other; urine samples had to be transported via the waiting room; patients enjoyed little or no privacy; staff were boxed up in tiny rooms; consultation areas were out of date and unwelcoming; the small waiting rooms meant that patients had to wait outside on occasions when these were full. Whilst the dedication and commitment of the staff were still very evident, their conditions of work—and the environment in which highly vulnerable patients were expected to discuss intimate and sensitive matters—were unacceptable.

114. Our visit to Manchester similarly revealed poor working conditions and an environment that was generally unwelcoming, not least to the young people who are likely to be the main users of services. We were told that, typically, GUM clinics are out of the public eye, tucked away in inaccessible parts of hospitals. They are not easily accessible to young people, as some of our witnesses, who were researching accessibility, pointed out:

Erica Buist)

(Sarah Nicholls) The GUM clinic in Wakefield, I had already been there twice before, but I had always gone by car, but this time I had to catch the bus because I was going from college and I could not find it ... I walked to the hospital and they had someone on work experience behind reception and by this point I was bright red. I was not really that bothered, but I thought 'Oh no! People are looking at me now', so I walked in and said 'Can you tell me where the GUM clinic is?' and he said 'I don't know'. There was nobody else around, so he had to ring a nurse to come and get me and escort me round ..."[102]

115. We asked the Minister whether the state of premises in GUM was acceptable and she acknowledged that they were "not good enough".[103] However, she was confident that, with the Government having embarked on "the biggest hospital building programme ever known in the NHS", over the next few years there would be "significant improvements".[104]

116. We note the very poor condition of many of the premises in which genito-urinary medicine is being carried out. Many strike us as being of an unacceptable standard and significantly below the general standard within the health service, as a consequence of the low status of this branch of medicine over the years. We believe that the very condition of the buildings makes them less attractive to patients and staff, less efficient, and less conducive to the necessary levels of privacy. Below we make recommendations about extending the range of settings in which GUM should take place, drawing particular attention to the advantages of the creation of a network of school-based clinics. However, we would urge the Minister to ensure trusts give due priority to the demands of GUM to compensate for the historic levels of under-investment. Unless sexual health is given higher priority within the health service we see no immediate prospects of widespread improvement.

CHLAMYDIA SCREENING

117. The Strategy specified chlamydia screening as an area needing development. As already noted, chlamydia is now the commonest sexually transmitted infection. The fact that in the majority of cases chlamydia is asymptomatic means that its prevalence is only likely to be reduced through screening.

118. The Chief Medical Officer's Expert Advisory Group on Chlamydia argued that specific target populations should be screened in a variety of healthcare settings. Screening should be offered to all GUM clinic attenders, in the view of the Group, as well as to all women seeking termination of pregnancy and their partners, and to asymptomatic sexually active women aged under 25 (especially teenagers and especially those who have had two or more partners in a year or a recent partner change). The preferred settings for testing, in the view of the Group, were General Practice and Family Planning Clinics. Referral for treatment should then be made to GUM clinics (although the Group acknowledged that some individuals would be unwilling to attend). Training would be required for GPs "who will have to decide whether or not to raise the issue of testing for a sexually transmitted infection when the patient is presenting for an unrelated condition".[105] Professor Anne Johnson of the Department of Population Sciences at the Royal Free Hospital listed antenatal clinics, abortion clinics, primary care and possibly the contraception service as potential settings for clinics, and in particular drew attention to the difficulty in capturing chlamydia in the male population, given the limitations of partner tracing and the fact that men would not access most of the obvious settings. In the absence of a widespread screening programme she anticipated that chlamydia would continue to present a "major public health burden".[106]

119. A pilot study to assess the impact of opportunistic screening for chlamydial infection has been completed at two sites, Portsmouth and the Wirral. This was funded by the Department and co-ordinated by the PHLS. The study also looked at the feasibility of opportunistic screening in a range of primary and secondary healthcare settings.[107] In a written answer to Sandra Gidley MP, the Public Health Minister, Hazel Blears MP said:

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120. Approximately 17,000 women were tested, equivalent to about 45% of the sexually active female population aged under 25 years in the area concerned. The results suggested that between 10% and 11% of women aged under 25 and attending healthcare services may be infected with chlamydia, with the highest rates being recorded in youth clinics where 17% were found to be positive.[109]

121. Dr Jean Tobin, a consultant in GUM and one of the managers of the chlamydia screening pilot, told us that the results of the pilot were so striking she would have preferred the Department to proceed straight away to a national roll-out of the screening programme:

110

122. Dr Kinghorn told us that the GUM specialty found it "very difficult to understand why we are rolling out in dribs and drabs."[111] Professor Anne Johnson argued that "a population based strategy" was needed since chlamydia was so widespread in society. However, Dr Muir Gray, Programme Director for the National Electronic Screening Programme which is involved in advising on the programme, suggested that targeted testing of the high risk population was what was needed. He did not support a call for an immediate national roll out until national standards for testing, quality assurance of testing, information giving and communication had been established.[112] He thought it was important that the results of a follow-up reinfection study were known before proceeding to a national roll out. A different view was taken by Dr Gwenda Hughes, for the Communicable Disease Surveillance Centre of the PHLS, who told us she did not believe that the benefits arising from refining the screening programme, in the light of the reinfection study, constituted sufficient reason for any delay in the screening programme, given the quantity of untreated infection in the community.[113]

123. We do not think that it is necessary to wait for the results of the reinfection study before introducing nationally the chlamydia screening programme. Any additional information that the reinfection study provides is, in our view, likely only to lead to modifications in the programme rather than fundamental reforms. Accordingly we recommend that the NHS must, as a matter of urgency, move to provide such screening in all family planning clinics, infertility clinics, termination of pregnancy clinics and GUM clinics and for women having their first cervical smears. We also believe that GPs should routinely offer testing to those aged under 25 years without attempting to second-guess patients' sexual behaviour.

124. Dr Gray told us that he thought that the best way of tracing and treating chlamydia in males was via contact tracing through female contacts. We are not convinced that this will be sufficient. We gather that the preliminary findings of the reinfection study suggest a high degree of reinfection in the community. Men are less likely than women to access any of the settings where it is suggested that screening can take place. Given the fact that chlamydia is usually asymptomatic in men, this poses real problems.

125. We recommend that the Department explores the possibility of offering screening and advice on STIs, including chlamydia, to men outside traditional health service settings. Imaginative solutions will be needed if the male population is to be engaged. School based services such as that offered by the Tic Tac project offer one possible avenue for advice, testing and referral (see below, paragraph 312). We would also like screening to be offered via community outreach schemes, for example targeting night clubs or sports clubs, especially in areas where high prevalence rates are recorded. We also recommend that the Government should assess the possibility of a much wider screening campaign, including a national screening day or series of regional screening days, promoted through a campaign of hard-hitting messages. Such a campaign should be introduced in an attempt to have a real impact on chlamydia in the wider population.

The test for chlamydia

126. Testing for chlamydial infection is by means of urethral samples in men and women, or cervical samples, urine samples or self-administered vulval swabs in women. Several of the memoranda draw attention to the greater accuracy and sensitivity of the newer molecular amplification test, such as the polymerase chain reaction (PCR) test, and to the fact that, for cost reasons, this is not always available.[114] In oral evidence, Dr Tobin suggested that only 10% of clinics used the PCR test, and that the enzyme immuno-assay (EIA) tests in common use would have missed 30% of women and 46% of men.[115] Dr Kinghorn estimated that fewer than 5% of GPs had the PCR test available to them.[116]

127. We were astonished to learn from Dr Kinghorn that even the chlamydia screening pilot sites, which had provided a stark picture of the extent of chlamydia in the population using the more accurate PCR test, had had to revert to the sub-optimal test following the completion of the pilots:

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128. Professor Johnson pointed out that there were potential long-term cost savings in the use of the more sensitive test if PID and infertility were reduced as a consequence of its introduction, given the very high costs of infertility treatment.[118] The Public Health Minister acknowledged that urine tests were "very acceptable" to patients, though she also felt that the self-swab test, whilst invasive, also had high levels of acceptability.[119]

129. We believe it is scandalous that a sub-optimal test, with an accuracy rate markedly below the best tests, is still widely in use in England for the detection of chlamydia. Indeed, we believe that health providers would be highly vulnerable to damages claims made by patients who had received a false negative diagnosis and had thus not had treatment for chlamydia infection. We believe that the Department of Health should issue firm guidance to the effect that the sub-optimal EIA test should be withdrawn in favour of the molecular amplification test as soon as possible. In some cases we realise that laboratory services would not be able to cope with sudden transition to these types of tests. Nevertheless, the examples of the Netherlands and Sweden, which we visited and which had long since abandoned EIA testing, convince us that it must be possible to move to the optimal test and we believe this should be an urgent priority.

57 Ev 387 (Specialty Societies for Genito-urinary Medicine) Back

58 Ev 387 Back

59 Ev 388 (Specialty Societies for Genito-urinary Medicine) Back

60 Q 518 Back

61 Ev 401 Back

62 Q 519 Back

63 Ev 352 (Dr Ranjani Rani and Dr V Smith) Back

64 Ev 377 (Dr Graz Luzzi) Back

65 Ev 330 (Dr Helen Lacey) Back

66 Ev 363 (Richard Pattman) Back

67 Ev 321 Back

68 Consultant Physicians Working for Patients: The duties, responsibilities and practice of physicians, 2nd ed, Royal College of Physicians, November 2001, p 27 Back