Select Committee on Health Third Report


1.While we have some reservations about some of the detail in the Strategy (and indeed about areas where there is scant detail) we regard as entirely commendable the decision of the Government to produce the Strategy. We would like to see measures going well beyond what it proposes, but would want to acknowledge that the Strategy represents an excellent starting point and a foundation which can be developed. (Paragraph 5)
2.Given the stigma around sexual problems, and given that those groups most affected by sexual ill health tend to be those whose voices are not heard in society as a whole, we can appreciate why patients might feel reluctant or even unable to complain. Primary Care Trusts need to make themselves aware of the patient's experience of sexual health services and work to improve this experience. Patient forums may be a route through which this could be undertaken. (Paragraph 27)
3.We recommend that the Army Medical Services forwards to the Public Health Laboratory Services its figures for STIs. We also recommend that the PHLS looks at how a more comprehensive surveillance system can be developed to cover all areas of sexual health and possible service providers. This will give a more complete picture of trends, prevalence and service utilisation. (Paragraph 50)
4.We welcome the recognition of the importance of research and evidence with regard to the provision of HIV/STI prevention. We recommend that the Government continues to support the Health Development Agency in developing an evidence base in the long term and that the Department ask the Medical Research Council to commission further research in this area of sexual health. (Paragraph 62)
5.In respect of the monitoring of trends in both STIs and HIV/AIDS we would like to pay tribute to the work of the Public Health Laboratory Service. Their monitoring ensures that the UK has the best data in the world, and this in turn gives great credibility to their research. It would be most regrettable if the absorption of the PHLS within the new Health Protection Agency were in any way adversely to affect its work. In particular, we would be alarmed if the close networks developed between the regional and local laboratories and clinicians and epidemiologists were to be impaired as a consequence of the move to NHS management of the laboratories (Paragraph 63)
6.Although we support the Government's drive to improve sexual health services via the Strategy, without wholesale advances in sexual health provision these targets will be tokenistic. (Paragraph 82)
7.The Strategy specifies that from 2005, commissioners should ensure that women who meet the legal requirements have access to an abortion within three weeks of the first appointment with the GP or other referring doctor. In our view, three weeks is too long for people to wait in these circumstances. (Paragraph 83)
8.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. (Paragraph 90)
9.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. (Paragraph 91)
10. 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. (Paragraph 91)
11.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. (Paragraph 92)
12.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. (Paragraph 95)
13.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. (Paragraph 110)
14.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. (Paragraph 116)
15.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. (Paragraph 123)
16.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. (Paragraph 125)
17.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. (Paragraph 129)
18.We are concerned by the trends in HIV and support the Government in its aim to reduce the prevalence of undiagnosed HIV and in turn to safeguard public health. Early diagnosis of HIV not only reduces the chances of it spreading within the community but it also greatly improves outcomes for those infected. On the basis of the evidence we have heard, however, we do not believe mandatory testing of asylum seekers, refugees, immigrants, visitors newly arrived in this country, and returning residents, to be an effective way of achieving the Government's aim. We recommend that HIV testing for newly arrived people should be voluntary, but should have as its clear objective the promotion of full disclosure of any relevant medical history and should also aim to facilitate appropriate and culturally-sensitive counselling before and after testing for HIV. (Paragraph 144)
19.We recognise that the field of HIV therapy is one which develops quickly and we appreciate that any guidelines on the use of HIV drugs might require frequent revision. However, we recommend that the National Institute for Clinical Excellence (NICE) should undertake an appraisal of treatments for HIV patients so that service providers and commissioners can collaborate and plan to make available the most effective treatment. (Paragraph 148)
20.Adequate funding for HIV drug therapy constitutes the only means of ensuring that HIV patients have access to the most appropriate drugs and that the other aspects of the sexual health service can be maintained and developed according to patients' needs. (Paragraph 149)
21.Now that funding for HIV services has been mainstreamed, and that commissioning is PCT-led, sexual health and HIV should be a priority at local level on grounds of public health. However, sexual health and HIV service providers have told us that they need help to persuade commissioners to allocate resources to an area which remains stigmatised, particularly in rural areas where prevalence of HIV is low. We are not convinced that the current arrangements will ensure that sexual health will be treated as a sufficiently urgent priority. Given that sexual health has no National Service Framework, and until NICE guidelines are introduced, we recommend that sexual health and HIV be included in Local Delivery Plans. (Paragraph 158)
22.We recognise that GPs and other primary care providers have an important role to play in the diagnosis and support of people with HIV as well as in their general medical treatment. HIV is a chronic condition. Dealing with chronic conditions is traditionally an area of strength for primary care. We therefore welcome moves to give primary care more of a role in the management of HIV/AIDS. However we are not convinced that the rebalancing of care provision is being sufficiently well supported. Accordingly, we recommend that these service providers be supported through training and through involvement in service networks. We also believe that it is crucial that the expertise currently residing within GUM is not diluted as a consequence of any move to primary care. So we would encourage any measures which promote close interaction between the expertise now found in secondary and tertiary services and that in primary care. (Paragraph 167)
23.We recommend that the Government should support the co-ordination of training for all social workers who have contact with those living with and affected by HIV, and also support the creation of posts for specialist social workers, who we believe could play an important role in developing and maintaining HIV service networks in high- and low-prevalence areas. (Paragraph 172)
24.We welcome the Government's acknowledgement of the voluntary sector contribution to HIV services. We have received a great deal of evidence to suggest that the voluntary sector can reach many HIV-positive people who will not access statutory services. We recommend that the Government reciprocate the support it receives from voluntary groups in terms of practical work and policy guidance by supporting voluntary work at both national and local level. It would be counter-productive if the Strategy led to any diminution in the funding given to these bodies. Some HIV services (such as targeted prevention work) can only be provided by organisations which are very closely in touch with their communities and these services must be adequately resourced. (Paragraph 178)
25.We recommend that commissioners participate in sexual health service networks, and that they should be accountable to service providers through transparent commissioning processes. Consortia are essential to the establishment of comprehensive service networks, particularly in rural areas. We believe that the Department must require Strategic Health Authorities to ensure that preliminary development of consortia is taking place, based on regional commissioning groups such as are in place for cancer services, so as to give a definite impetus to the development of networks. (Paragraph 188)
26.We welcome the guidance provided by the Department of Health in issuing the Commissioning Toolkit and also recommend that the standards developed by MEDFASH and The Specialty Societies in Genito-urinary medicine should be used by Strategic Health Authorities in managing the performance of trusts. (Paragraph 190)
27.We remain concerned that patient choice with regard to HIV and sexual health services will be limited should PCTs decide against paying for patients to use services outside the PCT area. We recommend that the Government, after consultation with commissioners and service providers, should issue further guidance and ensure funding arrangements which enable patients to access sexual health services away from their home PCT area if they wish, in line with the recommendations of the Monks Report. (Paragraph 191)
28.We recognise that the delivery of some sexual health services through primary care has considerable potential in terms of access and continuity of care. However, we have not been assured that General Practitioners will receive sufficient training and support to deliver services effectively, nor that PCTs will provide sufficient encouragement to GPs to offer improved sexual health services. These may be matters which could be addressed through the new GP contract. (Paragraph 195)
29.According to the Government, the prevention of unplanned pregnancy by NHS contraception services probably saves the NHS over £2.5 billion a year already. Despite this, we have received compelling accounts of disinvestment in these vital services, and the fact that contraceptive services are not even included within the Strategy's five aims is further evidence of this creeping deprioritisation. We recommend that the Government takes immediate steps to rectify this priority imbalance. (Paragraph 211)
30.If General Practitioners are to deliver Level 1 and Level 2 services to a high standard, the Government must ensure that the GP contract addresses issues of quality in relation to provision of contraceptive and other sexual health services, as well as giving GPs incentives to undergo further training in this area. The Government should also work with the relevant bodies to ensure that sexual health is given appropriate emphasis both in undergraduate medical training and in postgraduate education for trainee GPs. (Paragraph 217)
31.Many memoranda also point out that there is a serious shortage of national information currently available about the organisation and provision of contraceptive services. According to Dr Smith, a review of contraceptive services was carried out by the Department at a regional level ten years ago, but the results were never analysed or used to obtain a national picture due to lack of Department of Health capacity. Very little data are available about GP provision of contraceptive services. We recognise the importance of the collection of relevant information for the planning and delivery of services. We therefore recommend that steps are taken to standardise information collection in the field of sexual health, both for specialist service providers and general practitioners. (Paragraph 218)
32.With improved access to better contraception services as part of the implementation of the Strategy, we would hope to see a reduction in the number of unwanted pregnancies, leading to a decrease in the use of the abortion service. For those women who do seek access to the service, we believe that certain improvements should be made. We recognise the difficulties that would beset attempts to reform current laws relating to abortion. However, we support the FPA's view that access targets are meaningless without attendant measures to cut through the bureaucracy surrounding referral for termination of pregnancy. We believe, therefore, that the Government should, within the current legal framework which includes the approval of two doctors, promote a model of open-access for termination of pregnancy, based within Level 3 services, and accessed through a national advice line. (Paragraph 220)
33.We heard compelling evidence that for women who need to undergo an abortion, early medical abortion is a preferable option to surgery, as it carries significantly reduced risk of complications, and can be less distressing. The fact that early medical abortion does not involve any type of surgical process means that, with appropriate training and backup, it could be carried out by nurses rather than solely by doctors, and in community settings rather than solely in acute hospitals. However, at present early medical abortions constitute only a very small proportion of the total abortions carried out. We believe that allowing women access to early medical abortion in a wider range of healthcare settings would help reduce the number of late abortions which may occur as a result of long waits for surgery, and would also be a more cost-effective use of NHS resources. We therefore recommend that the Government should consider this option. (Paragraph 221)
34.We fully accept that any Government has to balance competing priorities and pressures in respect of public expenditure. We do, however, find it indicative of the priority accorded to sexual health, and sexual dysfunction services in particular, that access to anti-impotence services and drugs is so restricted. Effectively, the Government is dealing with this more as a lifestyle issue than a health issue, and that seems to us to be wrong. It is simply not appropriate that so many men and women with a clear medical and psychological need are not having access to these treatments, leading to a situation where only those who can afford it are likely to use them. This seems to us contrary to the fundamental principles of the NHS. We therefore recommend that access to anti-impotence treatments should be reviewed. We also think it would be helpful if the Department commissioned research to establish the costs and benefits of a more liberal prescribing regime, given the likely savings which might accrue in areas such as the treatment of depression, infertility, and dealing with the consequences of marital breakdown. Given the lack of development of sexual dysfunction services, and the fact that social pressures are such that those suffering will often be shy and unwilling to articulate their case, we call on the Department to include sexual dysfunction within the wider sexual health strategy. (Paragraph 230)
35.Sexual health promotion offers a long term solution to many of the sexual health problems which challenge society. It is clear from the evidence we have received that awareness-raising activity and information campaigns are important but they will not on their own bring about sustained behaviour change, particularly amongst those marginalised individuals, groups and communities most vulnerable to HIV and other sexually transmitted infections. We recognise the importance of targeted community-based initiatives, peer education programmes and outreach work and would urge PCTs to ensure these range of interventions are a central part of local HIV prevention and sexual health promotion programmes. (Paragraph 243)
36.We welcome the Department of Health's efforts to produce and disseminate a health promotion toolkit to support commissioners. In relation to sexual health, this should specify that all those providing services in any area of sexual health, including GPs, GUM clinics, family planning clinics, and termination of pregnancy services, should provide a full sexual health risk assessment and sexual health promotion advice to all patients, as clinically appropriate. We feel that health promotion services in the field of sexual health are absolutely vital, but are also one of the services most at risk of being marginalised and deprioritised, given that demand for preventative services is never articulated as vociferously by patients as demand for treatment, and that targeted funding which has been available over the past decade has been subsumed into mainstream allocations. There is a compelling rationale for continued investment in health promotion and prevention. If a healthier nation is to be created, sexual health promotion needs the support and capacity to make a difference. Resources need to be identified to maintain specialist health promotion services, which provide training and advice to health professionals and lead on community-based initiatives with target groups. PCTs should be held to account for the commissioning of targeted HIV prevention and sexual health promotion, both in terms of resource input and effectiveness measures. (Paragraph 250)
37.Our evidence from young people, which we discuss more fully below, suggests that even basic factual knowledge about sex and sexual health cannot be assumed, and we believe that providing young people with accurate and appropriate information through school relationships and sex education programmes is an essential building block for securing improved sexual health both for this and for future generations. We see no benefit in preventative approaches based primarily around promoting abstinence. However, the fact that many young people who have not had sex believe they are in a minority, and equally that a significant proportion of them regret their first sexual experience, suggests that they would benefit from more support in deciding when is the right time for them in respect of the management of relationships, and support to resist external pressures to have sex, which is why we firmly support the location of sex education within the broader emotional and social framework of sex and relationships education (SRE). (Paragraph 267)
38.In view of the clear inadequacy of provision relating to the context in which sexual behaviour takes place, we feel that a much greater emphasis on the importance of handling relationships would contribute to an improvement in sexual health. We therefore recommend that DfES give further consideration to whether existing guidance on the relationships aspect of SRE emphasises sufficiently the importance of this area. (Paragraph 275)
39.We recommend that the Department for Education and Skills and the Department of Health work together to compile a resource for schools detailing websites with high-quality information on sexual health which should be exempted from any filters schools may apply to their I.T. systems. DfES should also consider making 'electronic babies' more widely available in schools. The possibility of a text-messaging advice service should also be investigated. (Paragraph 281)
40.We strongly recommend that SRE becomes a core part of the National Curriculum, to be delivered within the broader framework of PHSE along with citizenship. We want to see education on relationships and sex given a high priority since the short and long term consequences of poor sexual health for young people, including unplanned pregnancy and parenthood as well as disease, can be so serious. (Paragraph 286)
41. While investing SRE with National Curriculum status will improve its standing, we believe that the key to improving educational standards in SRE lies in providing each school with well-trained, capable and enthusiastic SRE teachers. We recommend that the Department for Education and Skills reviews the way in which teachers are trained and SRE is managed in schools, ensuring that SRE is taught by teachers with specialist knowledge and expertise in the subject. We recognise the difficulties of scale that might attend ensuring that each primary and secondary school has a dedicated SRE teacher, but we believe that these logistical difficulties could be overcome through creative local arrangements, such as pooling a teacher or teachers across a consortium of schools within a local authority. DfES should also ensure that schools have access to, and make good use of, support from a range of individuals and agencies—such as nurses, GPs, health promotion specialists, peer educators and youth workers—when planning and teaching SRE. (Paragraph 292)
42.The Department for Education and Skills is currently engaged in work with the National Children's Bureau on guidelines specifically aimed at how to best engage boys and young men in schools-based sex education. We recommend that this guidance forms a specific plank of the National Curriculum on SRE, as clearly young men's needs have hitherto not been adequately addressed, despite the fact that they represent half the problem and half the solution to improving young people's sexual health. We were also struck by the fact that during the course of this inquiry, the vast majority of the people we met and took evidence from who were involved in sex and relationships education, and sexual health promotion for young people were female. One of the young men who came to give us evidence gave lack of specific male input as a key problem in the delivery of relationships and sex education for young men, and this is clearly a difficult problem that needs to be addressed. While we understand that it may not be practical for every school to provide both a male and a female teacher for SRE, schools must ensure that young men have access to SRE delivered by males, perhaps through using male peer educators, community workers and health professionals. (Paragraph 299)
43.It is imperative that all school-based relationships and sex education gives young people the opportunity to learn and think about the broader aspects of sex and sexual health, including emotions, relationships and families, and including the existence of different family structures. It is also vital that young people have a good understanding of the facts surrounding sexual health before they need them. Current guidance states that all primary aged children need to know about how a baby is born and about puberty before they experience the onset of physical changes; and that secondary school pupils should understand human sexuality, be aware of their own sexuality and know about contraception, sexually transmitted infections and HIV. We have seen little evidence through this inquiry that the SRE guidance is being implemented in a consistent way, especially in relation to more sensitive areas such as sexual feelings and emotions, sexual orientation and HIV and AIDS. We therefore recommend that the Department for Education and Skills establishes mechanisms (until such a time when SRE has National Curriculum status) both to monitor the implementation of the guidance and to assess the extent to which relationships and sex education, which addresses the needs of young people, is being delivered by primary and secondary schools. (Paragraph 303)
44.We welcome the efforts currently being undertaken by the Department of Health and the Department for Education and Skills with regard to helping parents talk to their children about sex, as we feel that this type of engagement has a vital role to play in ensuring young people receive rounded sex education. (Paragraph 305)
45.We strongly support the use of peer educators, and recommend that the Department for Education and Skills and the Department of Health should work together to continue to promote this approach in all schools, although we believe this should be a supplement to rather than a replacement of formal schools-based relationships and sex education. (Paragraph 307)
46.The Tic Tac project in Paignton, clearly an example of best practice in meeting, in a confidential manner, young people's sexual health needs, has been heavily driven by local enthusiasm and leadership, which has helped steer it through continuous funding uncertainties as well as negative publicity. It is seen as an integral part of raising educational standards in the school. However, we also heard of several examples of other schools which were keen to adopt the model, but which were obstructed by school governors. We believe that the Government should actively promote this model of joint service provision and education for young people, and make dedicated funding available to establish an appropriate number of such services within each local authority area. Although we recognise that it may not be practicable to have such a service attached to every school site, arrangements should be made between smaller schools to establish shared facilities or to devise links with dedicated clinics. We would also urge the Department to pilot a youth clinic along the lines of those we visited in Sweden: these may be more effective in reaching those not attending school. (Paragraph 312)
47.The crisis in sexual health services seems to us a consequence of several factors:
  • A failure of local NHS organisations to recognise and deal with this major public health problem
  • A lack of political pressure and leadership over many years
  • The absence of a patient voice
  • A lack of resources
  • A lack of central direction to suggest that this is a key priority
  • An absence of performance management. (Paragraph 319)
48.We therefore recommend that the Government takes urgent steps to ensure that access to high-quality sexual health services is prioritised and resourced. (Paragraph 323)
49.The best way of achieving this would be the launch of a dedicated National Service Framework for sexual health and we recommend that this be done. We understand, however, that the development of an NSF can take a number of years. Therefore, as an interim step we recommend that the Department should insist that sexual health is tackled, as a public health priority, at a strategic health authority level by adding it to the Planning and Priorities Framework 2003-06. The Department should set in place a rapid and urgent review of sexual health need, services, sexual health promotion, and treatment. This will need to be done jointly with SHAs and PCTs. To ensure that SHAs fully embrace this new responsibility, SHA Directors of Public Health should be responsible for the delivery of a 48-hour access target within their patch within two years, which should be supported by specific targets relating to reductions in the numbers of cases of the major sexually transmitted diseases. (Paragraph 324)
50.We are well aware of the danger of prescribing an NSF as the necessary panacea for any particular problem in the health service. There are numerous competing demands for priority and resources within the health service. However, the dramatic and spiralling decline in the nation's sexual health, the fact that this decline impacts most seriously on the most disadvantaged in society, and the danger that if nothing is done there will be a further deterioration with profound consequences convinces us that this is an area desperately in need of prioritisation. Further, we believe that the process of drawing up an NSF in this area could be expedited. The Strategy and its supporting documents already provide a very substantial basis, meaning that the development timescale could be condensed considerably. The Medical Foundation for AIDS and Sexual Health work on standards and networks could be woven into an NSF. If this option were pursued, in our view, the NSF should contain a maximum access target of 48 hours for access to a GUM or specialist family planning clinic, and be supported by specific targets relating to an eventual reduction in the number of cases of the major sexually transmitted diseases. As with other NSF targets, these should form part of PCT local delivery plans. (Paragraph 325)
51.  We have been appalled by the crisis in sexual health we have heard about and witnessed during our inquiry. We do not use the word 'crisis' lightly but in this case it is appropriate. This is a major public health issue and the problems identified in this Report must be addressed immediately. (Paragraph 326)

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