THURSDAY 28 NOVEMBER 2002

__________

Members present:

Mr David Hinchcliffe, in the Chair
Mr David Amess
John Austin
Andy Burnham
Jim Dowd
Julia Drown
Sandra Gidley
Siobhain McDonagh
Dr Doug Naysmith
Dr Richard Taylor

__________

DR GEORGE KINGHORN, immediate past president of the Medical Society for the Study of Veneral Diseases and Clinical Director of the Genito-urinary Department, Royal Hallamshire Hospital, Sheffield; DR PAT MUNDAY, Consultant Physician in genito-urinary medicine, Watford General Hospital; DR CHRIS FORD, practising GP and chair, Royal College of General Practitioners Sex, Drugs and HIV Test Group; MS MARIANE NICHOLSON, Chair, Herpes Viruses Association; MR GRAHAM TAYLOR, lead commissioner for sexual health and HIV care, Brighton and Hove City Primary Care Trust; and MS JACKIE ROGERS, clinical nurse specialist in genito-urinary medicine, Ore Clinic, Hastings, examined.

Chairman

513. Colleagues, can I welcome you to this session of the Committee and thank you very much for your co-operation with our inquiry. Could I ask you briefly to introduce yourselves to the Committee?

(Mr Taylor) I am the Brighton and Hove City primary care trust commissioning manager for sexual health and HIV services, with apologies for the long title.

(Ms Rogers) I am the lead nurse for sexual health services, and I am the lead for the two PCTs in our area.

(Dr Kinghorn) I am a GU physician from Sheffield.

(Dr Munday) I am a GU physician from a district general hospital in Watford, west Hertfordshire.

(Dr Ford) I am a GP from Kilburn, north London, and the chair of the Royal College of General Practitioners Sex, Drugs and HIV Test Group.

(Ms Nicholson) I am director of the Herpes Viruses Association which is a patient support group running since 1985.

514. Can we begin by asking you, Dr Kinghorn, a question about the increases in workload? I think all of us have been very concerned with the evidence that we have picked up and you have been involved in this area for a long period of time. Can you talk about the reasons you see for the increases and the pressures that the service is under? Obviously we have had evidence that suggests that if we use 1994 as a starting point that is not necessarily giving a full picture because of certain factors in the early 1990s. What would the picture look like if we, say, went over 25 years, for example?

(Dr Kinghorn) I started 25 years ago and in 1976 in Sheffield the workload in 2001 in comparison had quadrupled, but if we take it over a more recent period of time, if we look at the number of diagnoses made in GUM clinics over the past ten years, they have doubled. We now see something like one and a third million new conditions in GUM clinics per year. In terms of the new patients that we see, we saw 624,000 last year out of a total of almost 1.5 million total attendances. But in addition to the increase in numbers, there has also been an increase in complexity because GU medicine is the major provider for HIV treatment and care within the country, and if we look since 1996, when we had the start of an effective treatment for HIV, in my department the annual numbers that we look after, in fact, have trebled. Last year there were 4,500 new diagnoses; I have no doubt that the number of new diagnoses this year will increase because in my department we have had almost a doubling of new cases this year as compared with last. So we have had an increase in the number of cases in terms of quantity but also in terms of complexity. This contrasts with really the dearth of new resources particularly since 1997. We have seen that consultant expansion has virtually ceased over that period of time, and this has been at the time when we have had the greatest acceleration in the number of new cases, so that our capacity to cope with the patient workload has been well exceeded.

515. In the time of the 25 year period that you have been working, you have talked about the workload quadrupling in that period of time. Is it that we have got a similar increase in the incidence of disease, or is it that people are now more prepared to seek treatment and more aware of the need to seek treatment?

(Dr Kinghorn) I think it is a combination of the two. GU medicine clinics over the course of time have become more recognised for their expertise within this area; there is greater preparedness on behalf of patients to present. Undoubtedly AIDS education within the mid-1980s brought this to the fore but I think that we have to acknowledge, as has been shown in the NATSAL studies, that there have been huge changes that have taken place in sexual behaviour particularly in the past ten years. We know that the age of first intercourse is tending to fall: we know that the number the average number of lifetime sexual partners has increased, and it is almost inevitable under those circumstances that the number of individuals who will acquire a sexual transmitted infection will increase. I think the analogy will be similar to the number of cars on the road. The more cars there are on the road, it tends to be that there are more accidents!

516. I understand the point you are making! We may get on to this in more detail but in looking at where we go in relation to the strategy, these trends in sexual behaviour are perhaps a difficult area for any government to address. We learned, or some of us did, in Manchester about anonymous sex, which was a term that one or two of my colleagues had not come across before, but how do you see any government being able to address these wider societal issues which clearly need to be addressed in the context of looking at sexual health?

(Dr Kinghorn) I think that there always has to be a combination of approaches. There needs to be good education and good information, but that alone will never deal with the problem; it must be backed up by effective services. We are about to enter a time where there will be a national awareness campaign which will make clear that the proportion of individuals below the age of 25 who have a sexually transmitted infection may be more than one in ten. We will be emphasising that such infections will need to be detected by screening and that there is a necessity to present for health care. The concern that we have is that it is essential that the other part of this debacle, almost, is "we will inform you", but we must be able to pick up the pieces and help individuals when they present for infection, and our concern at this present time is that although the strategy provides an excellent framework in order to deal with these problems within the future, we do not have the capacity at this stage in order to meet the needs of young people in particular.

517. Do any of the other witnesses want to add anything, because there are some fairly wide ranging questions?

(Mr Taylor) I would like, surprisingly enough, to agree with my colleague. There is always a perception that commissioners and providers of service may well wish not to agree on a number of issues. The issue, as far as I see it, is quite clearly there is a rise in STI transmission and quite clearly there is an issue around the capacity of existing services to meet the existing need. If we are looking at national media campaigns, then what that means is awareness will be raised and people will want to access a service but if they cannot do that as quickly as they would like that means they will go back into the population and may well never choose to access that service again because then there is a perception that it is always going to be late, we are going to have to wait 14 days for an appointment - etc, etc. The issue for me and my clinical colleagues is always that I would very much love to be able to commission additional services, but the reality is that the time lag in the financial allocation process means that the health authorities that were, and primary care trusts that are, are always desperately trying to fund the combination therapy costs and the drug costs and do not get ahead of it so we can fund additional people to provide the service. I hope that is helpful.

(Dr Munday) I would agree entirely with Dr Kinghorn.

 

Julia Drown

518. I would like to ask about consultant numbers. Many people have written to the Committee and have pointed to the Royal College of Physicians' recommendation that there should be one consultant per 113,000 population whereas at the moment there is one per 400,000. The trouble is that in other specialties the imbalance is even greater. How do you move forward from that in terms of saying how many consultants really are needed, and is there an issue that perhaps some of the work could be done by other members of the clinical team?

(Dr Kinghorn) To answer the latter part first, there is no doubt that we need to make the best use of all of the skills of local disciplinary teams and that is a process which is already in evolution and happening. The latest manpower figures which we have from the Royal College of Physicians' survey 2001 show that we have 247 consultants in England, which is 238 whole time equivalents. Based on the number of excess notional half days that doctors are performing at this present time and to meet the EU directive, which causes me quite some concern, the numbers based on that that we need additionally are 180. Based on the Royal College of Physicians' recommendation, which has been revised to 1 per 119,000, we would require an extra 173 for England.

519. On top?

(Dr Kinghorn) Yes. We at present have about 120 specialist registrars who are in training and their training period is four years so our output of consultants potentially is around 30 per year. So clearly it will take us some time. Even if the will and the finance were available to meet our requirements during that period of time, because I believe that the latent demand for GU medicine services is even greater than has been indicated so far, it is clear that not only do we need to develop a specialist service but we have to make better use of nurses and health advisers in particular, and we need to be ensuring that our core services can spread out into community settings, and that is very important - to make sure that the services and the expertise can be nearer to where patients are, to make it much more accessible and, I hope, acceptable.

520. And, as far as you know, does the government accept or reject, for example, the figure of 180 to meet the EU directive?

(Dr Kinghorn) I do not know. Certainly I have not heard any criticism of the figures and I know that it has been accepted that there needs to be an increase in the number of trainees, so I presume that by that acceptance there will need to be an increase in the number of trainees, and that the number of consultants that are required has been accepted too.

521. You do not know to how many?

(Dr Kinghorn) I do not.

522. And also, within the Royal College of Physicians, is there any attempt to try and get agreement across the specialties that there is parity between the two different things? It is very obvious to us the huge pressure that you are under, but then we can see there may be an argument within the Department of Health when there are other specialties that are saying, "Our disparity is even greater". Is there any agreement to ensure there is parity?

(Dr Kinghorn) Within the College Committee we are very much alive to the problems and the needs of what is called modernisation - the needs to make better use of all of our staff. There is firm support for the strategy within the College Committee; there is no doubt about that.

523. I did not mean within GUM - I meant within the Royal College of Physicians and whether neurologists and GUM try and have an agreement about this parity - that one per 113,000 GUM is parity and one per X is neurology. Is that done?

(Dr Kinghorn) Yes.

John Austin

524. Can I go on to the delay in accessing services? We went to Manchester, and it is always my thought that Manchester is a special case because of the high pressure there but the evidence we have had from London, Sheffield, Wales - all over - suggests a similar problem in accessing services, and the Public Health Laboratory clearly says that delay in accessing those services increases the duration of infectiousness and the probability of disease transmission. Could you, Dr Kinghorn, tell us what effect you think the increase of patient numbers has had on patients' ability to access certain clinics, and what significance that has had in the rise of STIs and HIV infection?

(Dr Kinghorn) Can I just put this problem in perspective, because we have been so concerned that we have been doing regular surveys of clinics to find out how long it is before they can see the so-called routine patient, and we know that the median time in clinics in England now is 14 days and rising. To put that into some sort of perspective, the number of clinics who are able to see patients within a week is about 20 per cent; within two weeks, 50 per cent; and over a third are unable to see patients for three weeks or more. It is inevitable under those circumstances that with such delays in access they tend to affect those who are in most need in the greatest way, particularly the young people from ethnic minorities and those from deprived backgrounds. With young people there is a window of opportunity, and that is now. It is the day and the time that they present. In my view they should never be turned away, but that is happening. We know that some clinics, Archway in London, do not book appointments until one day beforehand and they have about 50 appointments for the following day. By 10.15 all of the male appointments are taken up and it takes about seven and a half minutes to fill up all of the appointments for the female patients, so that the demand and the number of patients who are turned away and advised to go elsewhere is three times the number of people that can be accommodated. That is potentially a disastrous state of affairs because some people will never come back. The longer that an individual has an infection for the more likely they are to transmit it to others. Not only are they more likely to acquire the complications of sexually transmitted infections which may be very serious for that individual for the future, but also they may be very costly. I think the issue which should concern us all is that the presence of sexually transmitted infections is a major factor in the acquisition and the transmission of HIV, so that the increased numbers of HIV that we are seeing at least in part are related to on-going and probably increased transmission. We are therefore running into problems of increased morbidity for the individual patient and we are running into problems of increasing amounts of very expensive HIV.

525. The Royal College of Physicians suggested that people should be seen on the day they present or the next occasion the clinic is open. Clearly that is not what you have described. Do you think that access targets should be set?

(Dr Kinghorn) Yes. The College of Physicians' recommendation was something that was contained within the Monks' Report in around 1990 and that was supported by ministerial letter. This was, as far as we were concerned, a directive: it was not something which was optional. It was a directive to us that we should see people within that period of time. We as GU physicians and working within the GUM service believe that still to be true, and many of us are seriously concerned about our inadequate access at this present time. I would always argue for the highest standard and I would not like to see that standard set before diluted in any way. However, general practitioners will be recommending that all patients should be seen within 48 hours. Surely for a communicable disease the standard should be no less than that.

526. Since money is a major determinant of decisions in most public services, you have indicated that delayed access in services not only increases the likelihood of transmission but you also said that it can lead to more serious consequences for the patient, more costly outcomes, more complicated consequences. Is there any way in which the additional costs of delay could be quantified in order to justify or better make the case for more resources in the first place?

(Dr Kinghorn) Last year there were 4,500 new cases of HIV. Each of those patients costs £12,500-15,000 of treatment care costs per year, therefore the additional cost of HIV last year to the country will be at least £56 million, and it will be more for what is happening in 2002. The costs in our view of implementing the national sexual health and HIV strategy in full will be far less than the costs of HIV, but I know that we are here particularly to talk about STI treatment and care today. In my department 1 per cent of my population is HIV infected. They take up more than two thirds of all of the resource within the department. I see 12,000 other patients whose cost of a completed treatment episode for GU medicine is about £150 compared with £12,500-15,000 for each HIV case. It must be cheaper to do the job properly.

 

Sandra Gidley

527. For the sake of clarity could I pick up on this: you describe the routine patient. Could you define a routine patient?

(Dr Kinghorn) They are often self-defined. "When would you like to be seen?"; "Immediately"; "When can you be seen?" Many clinics like mine will have a triage system so those who are most articulate will be able to negotiate their way round that system and will be able to be seen more quickly. Those who are less articulate, those for whom English is not their first language and those who are young, are less able to negotiate their way round that and therefore are likely to be longer before they are seen. A routine patient, in answer to your question, is simply one who rings up who wishes to be seen, but if we were to try and prioritise those patients, that requires an interaction with a health care professional to make an assessment as to the degree of urgency with which they should be seen.

528. Let us move on slightly to the smaller and part-time clinics. Are there any particular problems associated with the smaller units rather than the larger ones, and maybe Dr Munday or Jackie Rogers would like to answer this.

(Dr Munday) Thank you. Small clinics are usually run by a single-handed consultant with one or two or three nurses and perhaps a health adviser, and open one or two, or maybe three, four or five days during the week. When that consultant is there, the service runs. When the consultant is not there, the service closes. So that in order for the service to run, one has to take into account the need for annual leave, for study leave, for maintaining clinical governance requirements and for negotiation, so all those impact on a consultant's time and reduce the time available for clinical care.

529. Can I ask a very silly question? Does the consultant have to be there in order for the clinic to run? Can a more junior doctor not run it?

(Dr Munday) There are no junior doctors.

530. So it is a single-handed practitioner?

(Dr Munday) Yes. Single handed consultants do not have junior doctors, and most clinics in the UK are run by consultants and non consultant career grade doctors without any junior doctors around. That is the model of care. In my department, for example, I am a single-handed consultant with several non consultant career grade doctors who are part time and who work with me, and I have a part-time junior doctor and that is it, and I see 17,000 patients a year. You will see that is a lot more than Dr Kinghorn sees in his clinic with four consultants and all the junior doctors and all the staff he has. So it is an enormous workload.

531. What happens when you go on holiday?

(Dr Munday) My non consultant career grade doctors cover for me, and in fact that is not really recommended by the College of Physicians but we have no option. That is how it has to work, otherwise the service would close. They are running the clinic now as I talk to you.

Dr Naysmith

532. Are you saying that there has to be a consultant on the premises?

(Dr Munday) There has to be a doctor on the premises.

533. So these junior doctors who do work for you, although you said you were single-handed, can operate the system when you are not there?

(Dr Munday) They can but they really need to have access to a consultant if they have difficult cases.

534. Sure, but a fair amount of the work must be fairly routine?

(Dr Munday) Yes. I think it is fair to say that my clinic is quite a large single-handed clinic as compared with many others. There are many clinics which have a consultant and maybe just one or two GP clinical assistants doing a couple of sessions and that is it, there really are no other people around, so during most of the time the consultant is seeing all the patients, him or herself.

Dr Taylor

535. You have highlighted the problem of the single-handed consultant which goes right across all specialties.

(Dr Munday) Absolutely.

536. The only answer, and it is being found in other specialties, is much more networking and you have absolutely pointed to the difference between the service you are able to provide and the service Dr Kinghorn is able to provide. There has to be networking. Have you looked at that? Is that geographically possible?

(Dr Munday) Yes, I think it is possible, but we need funding for the new posts.

537. I realise the tremendous under-funding of the whole service but in the short term, before the money is necessarily there, could you share existing services to improve yours without running Dr Kinghorn's down so much?

(Dr Munday) I think that the big teaching hospitals are absolutely overwhelmed anyway. They do not have any spare resources to pass on to us.

(Dr Kinghorn) The concept of networking is key for the future. There have to be within authorities, within district networks, between ourselves and primary care, networks across districts. Within my setting that is done by shared consultant members and that is quite key. I am a great believer that you need high quality doctors and it is best to share those across two locations rather than to have them located within one setting. My argument would be that I want there to be high quality services wherever people live, and the other part of my argument is I do not want to be doing any more work than is necessary because, if there is a service which is good in one place but not necessarily good elsewhere, patients will move. They will migrate - or at least a proportion will - and it is therefore in everybody's best interests. It is also essential from the point of view of clinical governance. None of us need to get isolated, and certainly our strategy for the future is that new consultant posts will be shared across networks between district general hospitals and teaching hospitals.

Sandra Gidley

538. Would Jackie Rogers like to comment on the smaller clinic?

(Ms Rogers) Yes, because I am very much involved in one. I think one of the big problems is the time constraint of clinics because if you have a part time service then you can only see patients within certain hours. It means you have a limited number of patients you can see and we therefore have to use an appointment system with some flexibility for emergencies, of course, but it means you can only ever achieve a certain number of patients within that time physically. It also means that, if you have a part-time consultant you usually have sessional workers and they come in just to work sessional hours, and if they are only there for sessional hours then those are clinical hours and there is no time for teaching, for meetings or clinical networks, and it means it is difficult for patients to access a service out of hours if they want to ring for advice, if other professionals - primary care, for instance - want to call us or contact us for advice there is nobody there - in my case I am, but most of the time there are no other staff - and that is very limited, both from the patients' point of view and from our other colleagues' point of view, and it is frustrating within the service because you do not have the time to meet and to train and to discuss and to network. Everything has to be planned into that clinical time because it is so precious.

539. So where are people directed when you are not there?

(Ms Rogers) They are directed back to their GP; they have to because that is the only other option and that is why it is so important that we are giving the same messages and we have the same standardisation of care, and that is where the strategy is in the PC report. We do triage, as most clinics do, and sometimes it is a matter of giving some advice that will help that patient get to the next appointment. Very often it will be their own anxieties that puts the pressure on the service and they can wait for an appointment, but it is very frustrating for us professionals to say, "You have to wait", because you never know. You cannot tell over the telephone.

540. No, quite. What happens in districts where there are not any departments of GU medicine?

(Dr Kinghorn) It is a black hole but what should happen is that there would be an agreement between that district and the adjacent one that they would provide the service. I would like to be able to say that money would follow their patients - that does not always happen - but clearly those groups who live in those areas are going to be disadvantaged compared with people next door. The demand is there but inequalities will be encouraged by the absence of a service.

541. We had a local problem recently in as much as at Basingstoke Hospital the managers I think decided they would like to cut out the HIV/AIDS cover and that it would be fine for people to travel to Southampton, which is quite a distance. Is that a fairly common occurrence? It is not going to happen I am glad to say, but how frequently does that situation arise?

(Dr Kinghorn) I think it is uncommon. It is a very unusual and, indeed, bizarre decision and I am very glad to see that it was reversed. People should be able to receive high quality care in the place where they live and for communicable diseases we cannot afford to delay. In answer to one of the questions earlier, the difference between neurology and GU medicine is that my patients have something they can transmit to someone else; that is why it is important. There is a public health imperative. It is not just a moral or a health matter for that individual: it is the fact that potentially that problem can be transmitted to others and the problem will multiply, so having accessible and high quality services locally for the range of conditions is important. Certainly expertise and some aspects of HIV care and in-patient care may well be localised within a network, but it should be within a network and there needs to be good liaison between the local provider, who is likely to provide most of the out patient care, and the inpatient care. It should happen by planning; not by default.

(Dr Munday) The idea of HIV services being conducted only in large centres has indeed been floated - it was floated in my particular trust about the time that antiretroviral therapy became available, and the trust was looking at the potential costs to their population. Fortunately they did not go down that path but I do think that units such as mine on the periphery of London are always going to be vulnerable to pressure from PCTs to reduce the HIV workload by sending patients down on the train into London, and particularly with the patients that we are seeing at the moment, who are largely patients from ethnic minorities, their ability to get a bus fare to come to our clinic let alone find their way into central London is compromised by the current situation, and I think they would be lost to the service if they were forced to seek their care in central London.

Chairman

542. Can I pick up a point, Dr Kinghorn? You are talking about this being a public health issue and certainly some of the concern this Committee has had over a long period of time has been the way in which we have perhaps lost some direction on public health. What are your thoughts on the role of our public health professionals in respect of sexual matters, particularly as they are located within PCTs? Do they engage in this issue at all? We picked up a crisis but I am not getting idea that public health professionals are trumpeting about crisis in a way that, were they aware of it, I would expect them to do.

(Dr Kinghorn) I think there is a degree of truth in that. In many places the local control of sexually transmitted infections has been a matter for the GUM physician. In an ideal world there would be at least three different individuals involved - the GUM consultant, the local CCDC, the local public health doctors, and the microbiologist - then you can get a picture of what is going on. Clearly primary care is essential and there need to be good links there too. Because of the confidentiality issues with regard to genitourinary medicine I think public health doctors in the past have been less involved than they might have been. Certainly we get very good support from CDSC, the Communicable Diseases Surveillance Centre, in London but locally the support often has been lacking - but that may be our fault. Maybe it is our job, in fact, as clinicians to make sure our public health doctors are aware of this situation, understand the public health importance, and also are helping to champion the cause of the people that we look after.

543. What worries me about this whole area is how we can ensure that the kind of crisis - and I do not use that term loosely - that sexual health is facing in the UK is somehow brought into the main stream of political debate. One of the problems we have is as MPs. I have been an MP for 16 years and I do not recall ever having a letter from a constituent about difficulty accessing a GUM clinic. It is not the sort of thing that happens. Therefore, if MPs are not made aware of these difficulties, how does the democratic process change what is a very serious situation? I am looking at the mechanisms of the professionals involved and why those mechanisms involving the public health people are not clicking in to ensure that we have in the Department of Health a response to what is a very serious and worrying situation throughout the country?

(Ms Nicholson) Doctors are trying to do their best with the limited resources. The people with the money have got to give it to all their people and all the departments in the National Health are all screaming for more money. In the case of baby units and cancer and hip replacements, you have the patients speaking up for their needs. In GUM, apart from a few HIV groups, no one is prepared, as you said, to write to their MPs so it is unique in that way. The shame of having a sexually transmitted disease keeps the patient quiet and doctors, I am afraid, have just got to take on the burden of speaking for them, and there has to be an understanding from the people who can disburse the money that in this case you have to listen to the doctors with more awareness than you would in other specialties.

(Mr Taylor) To an extent I would agree but clearly there is also an issue about people not wanting to self-identify anyway, for a whole range of reasons. It is not just about stigma and shame; it is about attending the service once or twice and then not again. It is not like you are going back for regular outpatient appointments or sessions. Somebody asked me a little while ago, "Do you consider yourself to be a user of the GUM service?", and my answer was no which is interesting. If I am saying "No" and I am the commissioning service and I go along once a year for my regular MOT, then of course the population itself will predominantly think, "Of course not". It is not just about attitudes around embarrassment; it is about not self-identifying because you do not go frequently enough. The other issue around public health networks for me is around the priority it is given by the government. I know it is part of the reason why we are here today but, if you look at the priorities set by the government, prior to shifting the balance of power which identified the shift of primary care trusts, there was a whole set of "must do's". "You must meet this target"; "There is an NSF for this"; "You will stand on your head and multiply by three" - a whole set of things had to be done. After shifting the balance of power, the responsibility then rested with PCTs so consequently anything coming out post PCT development has changed the language. It is about setting standards and local PCTs deciding what they want to do. If you then present a PCT with something that was prior shift of balance of power which is all around "You will do this, this, this and this", then you have something else coming out saying, "You might also want to think about these things", and a PCT chief executive is asked to respond and performance manage a whole set of criteria which do not necessarily include much around sexual health and HIV, what are they going to choose? I know - the same as everybody else: the things they have to deliver. Consequently their focus will, to an extent, be on what they have been told they must do. That is not a criticism of chief executives but a reality of the structure we are currently operating under. So we have that slight change of terminology which in this situation may be quite, and is, unhelpful from my point of view because it does not raise the profile. That is why the public health networks may well not be coming to you and knocking on your doors, or why individuals are not writing to you.

Dr Naysmith

544. I would just say that I have never had any representations from patients about GU medicine, but I have from professionals working in this area who complain to me about the levels of service.

(Dr Ford) This is one of the fundamental problems because patients are part of society and if society thinks that sex is a dirty subject then patients get that feeling. One of the slight problems with the strategy was that it was very much pushing a medical model rather than, "Sex is fun, most of us have it, it is a very positive experience", and that should be pushed in terms of education around sex, how to have good sex, and sexual health for all. If you look at every other European country, sex is taught much more openly. Terminations in young people are much lower because it is something that is talked about - it is not under the carpet. We were doing some training just recently with primary health care staff and their members of society, and a qualified nurse was saying to me, "Does any anybody have sex outside heterosexual relationships in marriage?", and this was a very genuine question and she is just one in society, so changing our general attitude to sex and sexual health is vitally important.

Andy Burnham

545. Are you saying that there is something peculiar about the British culture or character that makes these issues more problematic and complex than they need be compared to Europe, where they do not have the same problem?

(Dr Ford) I think they address it in a different way and certainly it is talked about. There are similarities in terms of drugs and the way drugs have been talked about - people are given education and should be able to make a choice. The number of young people I see who have never heard of chlamydia and who go to wherever and get contraception; they get the contraceptive pill but no information is given to them about what problems they might get into.

546. Would you not see the same scenario in a very Catholic country where that same openness is not there within the schools? Does that not show up in the statistics in the same way?

(Dr Ford) Did you say in Ireland?

547. In any Catholic country?

(Dr Ford) I have not got that information. I presume that it probably is a similar situation. If it is under the carpet, if it is not out there, then it is potentially dangerous.

548. Equally you might argue that, because it is out there, it has led to the trends in the NATSAL survey - that people are having more sex earlier, younger, and picking up more sexually transmitted infections?

(Dr Ford) If you look at Holland, for example, sexual information is given to children much younger than in this country, and sexually transmitted infections are lower and terminations are lower because good information is given so people can make a choice.

549. We have a situation in this country where we have made more information available in the last twenty years and there is now more sexual activity at a younger age, so there is a correlation, is there not?

(Dr Ford) Where is the sexual information being given?

550. I think there is more sex education in schools, is there not? There is more access to contraception? There is more openness than there was, surely, twenty years ago?

(Dr Ford) I think you have to look at the quality of what is being provided down on the ground in schools. Certainly the sexual education that my kids got was slightly questionable.

Chairman

551. Did you say "questionable"?

(Dr Ford) Questionable, yes. "Don't do it", sort of thing, which did not give them the choice!

(Dr Kinghorn) I do not think the correlation is necessarily between the sexual behaviour that is promoting STIs and the amount of sex education. The fact is that there is an imbalance between the promotion of sex within the media and within society and that is what has led to the increase in sexually transmitted infections and the imbalance has been too little, or inadequate, sex education. Many of us would dispute the suggestion that it is the increase in education that has led to the change in behaviour.

(Dr Ford) I agree.

Chairman: Interestingly, your comments were echoed very much by a group of young people in Manchester. They made exactly the same point.

Dr Taylor

552. On public health, more and more directors of public health in PCTs are not medically qualified. Is that good or bad from the point of view of your subject?

(Dr Kinghorn) I will answer that from the point of view of a doctor, and I think it is not necessary that they should be doctors but I think that they need to have a good understanding of public health issues, and particularly those that relate to communicable diseases. We are at an unfortunate time whereby commissioning has changed. We are in this process of change, and to a certain extent we have inexperienced commissioners. Indeed, many of us are finding it difficult to find who is our lead PCT for sexual health, and even asking the department for such a list has not yet produced it. Many commissioners are saying "government priorities": NSF obligations are only for those things which are to be funded by PCTs. Sexual health, STI treatment and care - even HIV - are not priorities. The typical response we hear is that there are no significant targets for sexual health. These are the responses that my colleagues are receiving from their commissioners at this present time. A good director of public health does not need to be a doctor as long as they have the insight and good communication.

Mr Amess: I find what Dr Kinghorn had to say fascinating because I wholeheartedly agree in terms of the treatment of sex by the media. You only have to turn the TV on and everyone is at it, so is it any wonder ----

Chairman: It depends which channel you watch!

Mr Amess

553. It is everywhere. It used to be on Channel 4 and 5; now it is on the BBC - everything. The whole thing has been trivialised. But just to outbid our Chairman, I am now in my 20th year, and I have not had one letter on the issues that you are talking about. I have had letters on fertility, people wanting sex change operations and transvestites but your lobby clearly is not being heard, so for us members of Parliament it is new that we are in such dire straits. I do not know who is responsible for organising your lobby but you need to get a handle on them and get more engaged in this. Turning to Jackie Rogers, we all know how difficult it is to recruit and retain nurses and I would just be very interested to hear from you as to what you think nurses are being used for in terms of delivery of sexual health services - whether you think they are under-utilised, or just what your opinion is generally. I think I know actually.

(Ms Rogers) I think you do! It is very variable, as I am sure you have heard across the country. In some areas nurses are still just chaperoning, doing very basic tasks and taking out specimens, and in other clinics they are delivering a much more holistic service; they are running nurse-led clinics and that would involve sexual history taking, assessment of the patient, examining them, doing the microscopy, and then giving treatment and advice using patient group directions, so it is a much fuller role. If you bear in mind the fact that there are more nurses employed in delivering sexual health services than doctors or health advisers, they clearly have a very important role and potentially for the future they can make or break the sexual health strategy, so I think we do need to look much more imaginatively at how they can be used, and I think that most nurses would say that the senior nurses within departments should be involved very much more in designing and planning the models of care that are delivered and looking at things like accessing and timetabling - that sort of thing. So nurses could be and want to be much more involved than they are in lots of cases, but they are restricted by the traditional model in too many still.

Mr Amess: Dr Taylor when he was a consultant did not jealously guard treatment services --

Julia Drown: I am not so sure about that!

Mr Amess

554. -- in terms of nurses but obviously there is an underlying tension there in that the government wants nurses to do more. Is there a great variation in your experience in the way clinics are used in terms of what the nurses do and how they react with the consultant who is there?

(Ms Rogers) Yes.

555. It depends on the personalities really?

(Ms Rogers) It depends very much on the personalities, but they are multidisciplinary teams - that is the way GU medicine has always been - because we only have the patients who maybe will only access that service once so we have to get it right. We are very special in that way in that we work as a team and that team approach is really important, and the nurses usually want to be very much part of that.

556. I think Dr Kinghorn is itching to say something.

(Dr Kinghorn) Yes, I am. As I was saying before, we were doing regular access surveys and we have done two this year because we are so concerned, and what we found in the second survey that we have just done is that the number of nurse practitioner sessions which Jackie has been referring to has increased by 30 per cent over this past year. I think as a doctor I am very aware of the importance of the impact of developing the nursing role - it is extremely important in my department - and the way we are going to get good practice spread is via networks. Good practice in one place, in fact, with linked posts and consultant posts and nursing and health adviser posts will allow us to go through this process much more quickly. For those of us who might want to be ostriches our time has gone, and it is the only way that we will survive for the future.

557. Finally on this point, Dr Munday, in your evidence you have certainly given the Committee the impression that all is not well in Watford and you have spoken about the fact that you wanted a consultant which was rejected, and then just to stick the boot in they thought they would cut your budget by £200,000 and so on and so forth. Could you give us a little bit more detail?

(Dr Munday) We had a very successful service in the early 1990s. We expanded. In 1991 we saw 5,500 patients; we had 2.7 full time equivalent doctors and 4.7 full time equivalent nurses. After 1995/6, we had no additional funding and by 2001 we were seeing 17,000 patients with 3.7 full time doctors and 5.1 full time nurses. That is an increase of one doctor and one nurse for an extra 10,000 patients. The situation became critical in January of last year when we saw 35 per cent of all patients in January of that year as compared with January 2000. I went to the chief executive for emergency help. I wrote to him; I e-mailed him and I telephoned him on several occasions. I got no response. After several weeks of continuing this and eventually threatening to go to the media, he passed the problem on down to a senior manager who had no ability to make financial decisions. I also wrote to the director of public health and to the consultant for communicable disease control locally. I tried to find a lead for sexual health from the health authority but there was not one. Meanwhile, several of my staff resigned and a couple of nurses went on long term sick leave, meaning that we could not sustain services. We had to keep closing doors because we just did not have anyone to see patients. I went back to the trust board eventually and asked for some support and they said they would talk to the PCTs about the possibility of a new consultant post. That fell through because it was not a priority in the local health economy. Meanwhile, the trust structure has changed. There is a completely new management team and the deficit in the local health economy is such that everyone is being asked to make cuts. I have to close down my outreach team which has been running successfully for several years. I have already taken one of my outreach posts and converted it into a health advice post. My final outreach worker I managed to convert into some local consultant sessions which lasted for eight months. I went back to the trust and said, "Can I have another four months of money to keep this person in post so that we can keep seven sessions open?" and they said, "No." It has been one reverse after another. The local health economy is in dire problems. It is one of the worst health economies throughout England. Their priorities are first to balance the budget and second to balance the budget and third to meet targets around access, waiting times, cancer waits and framework issues. There is no money left for us and we are having to make savings in order to fund the deficit against a vastly increasing workload.

Jim Dowd

558. You say that the trust has been in financial difficulties for ten years or so but it looks as if things went pretty well during the 1990s as the demand for increased services grew and you were able to respond but the wheels seemed to come off last January for some reason. Why then?

(Dr Munday) We have gone on increasing our patient numbers within the framework which we had. We run an open access service. That means the doors open at such a time and close at such a time. We will see all the patients who appear during that time. For example, on Monday, we do a morning session which will be advertised at 9.30 to 12.30 and at 12.30 we close the doors and there will be another 15 or 20 patients still to see. We finish maybe at two o'clock and we reopen at 3.30. The real killing thing is the evening sessions. By seven o'clock when we close the doors, there will be 20 new patients to be seen. My nurses were sitting around at 9.30 or ten o'clock, still seeing patients and they just could not take it any longer. The thing which really hurt us most was the fact that local clinics moved away from open access to appointment sessions. Everyone said, "Go to Watford. That is still open access. You will be seen in Watford." We were seeing people from all over north London and the home counties. It went on and on and we could no longer cope. It was a number of factors which brought about that enormous increase in workload over a short period of time.

559. The resources that the trust allocate to you have been cut considerably since January last year. How does it look incongruous that you are seeing 15 per cent more people than you were last year?

(Dr Munday) Because my staff work very, very hard to get them through the doors and out again. The quality of the service has declined but we still feel that it is important to maintain an open access service.

560. The quantity has gone up but the quality has deteriorated?

(Dr Munday) I think so. We cannot give the patients the time that we used to and we are cutting corners all the time.

561. Is it an acceptable service that you are providing?

(Dr Munday) Just about at the moment but we certainly could not cope with any more.

(Dr Kinghorn) We have highly motivated staff who have long worked in GUM clinics but you get to a stage whereby, despite your best efforts, you are doing a bad job. That is the worst thing when you go home. That is when morale suffers. That is when you get sick. That is when you really do not want to go into work to do another bad job on another day. You tend to go off sick or have some sort of problem and that puts more pressure on. You get to a stage of melt down. The situation we have within many GUM clinics which have been extremely well run is that we are running a risk of melt down.

John Austin

562. What does cutting corners mean?

(Dr Munday) It means spending less time on sexual health promotion ultimately. It means giving them the treatment and pushing them out so that you can see the next patient.

Chairman

563. Not preventing others coming in the future?

(Dr Munday) No.

Jim Dowd

564. On the broader question of skills shortages and the problem of recruitment and retention across all kinds of health service activities, is it any more acute in this branch of medicine?

(Dr Kinghorn) Within the specialist service, we have consultants for whom we do not have jobs at present, but we have the skills which are available to a limited extent. However, in order that we improve sexual health care as a whole, there must be an increased role for primary care. Teaching and training in primary care is quite key. They need to have the time, the resources and training. There is a skills shortage and a time shortage within primary care at this present time.

565. Do you mean GPs?

(Dr Kinghorn) Yes.

566. The service needs to be decentralised.

(Dr Kinghorn) There needs to be extra emphasis on the service and additional care provided within primary care. Many GPs -- my wife is a GP -- have said, "We have so many pressures upon us at this moment in time; how to fit this in seems to be very difficult." Many people do not feel that they have the skills to deal with level one services. We as specialists need to spend a lot more time giving support and training to our colleagues in order that we can have this augmental service within the specialist services and within primary care in the future.

Dr Taylor: Dr Munday has highlighted one of the most important messages we should be passing to the government. Although everybody welcomes the large amount of extra money that is coming it, it is being mopped up by deficits and there is none left at the moment for the advances that are so essential. I think that is one of the crucial messages that we should be getting across so that people do not expect magic improvements absolutely immediately.

Chairman

567. As this is being broadcast, if we have young doctors or people who are doing medical training looking in, one wonders what will attract them to this area of medicine in future. What attracted you in the first place to come into this area? If we have a better national agenda, what do you think will bring people into this specialty in the future?

(Dr Kinghorn) We all started off in mainstream medicine. The difficulty with medicine, certainly when I was in training, was that so much effort was given to the management of end stage disease. We were palliating most of the people we were looking after. The great attraction of what we were doing was that we were curing people and we were doing it with a younger population. It mattered. The impact of what we did was so much greater. I do not think that has changed. We have also lived through the advent of HIV which has been very much at the cutting edge and which has made the specialty attractive to many very able, young doctors. I still think that the most important thing is that many of the people we look after we cure and it makes a very significant difference.

(Dr Ford) Primary care cannot take on this role if there are not well supported specialist services to work in local and regional networks. There are increasing pressures from every direction on primary care and the strategy very much set a role for primary care in there but it came with no new resources. We cannot be expected to take on this added role. Sometimes people say it is primary care whingeing about money. Our workload has gone up; patient demand has gone up and if we are going to be able to do this effectively we very much need resources, both financial and human. We do not have a consistent training programme. As a medical student, I got no training around sexual health. I have done some obviously but it is not given emphasis in undergraduate and postgraduate training. There is no consistency in that training and if we are going to take on this role it is very important that that is addressed.

(Ms Nicholson) We hear from a lot of patients all over the country with herpes simplex and we hear frequently that a woman, when she goes to her GP with a sexual problem, an itch or a pain, the doctor will say without any sort of examination, "It is probably thrush", and give her a prescription for Canestan. Since the doctor clearly has no competence in GU medicine, at least he has spared the woman the embarrassment of an examination. While some people do prefer to see their GP with a sexual health matter, there is a high proportion of people who really opt to go for the anonymity of a GUM service. That has to be maintained quite separately from the primary care network. We hear of people who will travel to nearby towns rather than go to the clinic in their own town. This may be because they still have open access but when they speak to us about it it is because they want the guarantee of anonymity that going to a nearby town would give them. We do hear of embarrassing incidents where a patient goes to a GUM clinic and there is someone on the staff who makes some sort of recognition comment. We are embarrassed about sex in Britain with our prurient and puritanical attitude.

(Mr Taylor) The primary issue around primary care is not one about decentralisation. It is about additionality. There is no point in decentralising a service that works very well. If we are going to look at developing primary care services, we have to have training in place to help GPs and practice nurses understand issues and to be knowledgeable about them. Then you have to have space in which they can practise. If they already have an existing case load, there may need to be additional space in the GP practice. You also have the issue around the IT system. If you are looking at contact tracing for people in the primary care setting, finding their sexual partners, it is quite a hard thing to do and it takes a lot of time. I do not think anyone within the primary care setting has the additional facility at the moment to do that. We have been looking at providing sexually transmitted infection training for GP practices but then what? You are going to need to have people working between the GUM service and the primary care service on contact tracing. It is not as simple as it might appear. Logically, if we can provide additional services elsewhere other than in the GUM service, of course it will reduce the pressure on the GUM service, but if you are going to develop those services initially that means you take people out of the GP setting and the GUM setting to provide the training. Ironically, there is less time for you to see anybody so in the short term you have fewer appointments available at a time when you are trying to develop a service. It becomes quite difficult and you cannot fund the additional service so you almost need bridging funding to pay the people to come out of the GUM service so that you can provide the training.

(Ms Rogers) I wanted to go back to recruitment and retention of staff. It is difficult throughout the health service, particularly for nurses. Having got the nurses in your service, it is then keeping them there because there is no career pathway. That is becoming a big issue for some clinics, certainly within city centres where they can move from clinic to clinic. They find that they are all inundated with work and it is not rewarding. We need to start to equip nurses and to make them think about sexual health pre-registration. It should come into their training anyway. We need to have the resources so that we can relieve nurses so they can go off to do post-registration training and we need to look at a career pathway for them.

568. You say this should come into the training, implying it does not currently.

(Ms Rogers) It is touched on.

(Dr Ford) People should retain the ability to go somewhere anonymous but it has a negative effect as well. If we look at what happened to HIV, it was special and different. It went to a consultant. Do not talk to those naughty GPs because they do not know anything about it. It has taken us 15 years and we have moved on from that. Most of us in general practice are managing a lot of HIV care. HIV is a chronic, relapsing condition, which we are quite good at dealing with in primary care. The example used about thrush is bad medicine. That may be to do with ignorance, lack of training or whatever but I would like to change that. If that person went with a discharge, they should see somebody who knows what it might be and who is able to take effective swabs. If they cannot deal with it, then they should refer on to a specialist. That is what happens in all other specialities. When I cannot manage it, I send it on to a man or woman who can. It seems slightly bizarre that we have a different model in a few subjects, one of them being GUM. To be able to do that, primary care has to have the right screening and testing facilities. In the surgery where I work, the chlamydia screening I use, if you are very good at it, can pick up about 60 per cent. If you go to the local specialist, they say they have something and if you waft it anywhere near the part it will be picked up. It is completely bizarre that I am the inexperienced person using a test. Nobody else would recommend supporting a test that does not pick up, for example, chlamydia. We should have effective screening and diagnostic facilities available in primary care.

569. While we are on the relationship between primary and acute sectors, can I throw in an issue that this Committee has looked at? It may be completely irrelevant but is there any use of telehealth and teleconsultations at all within your area of work? Do you know of any primary care centres that may connect with local GUM specialists in a nearby acute hospital? Does it have any potential or is it completely irrelevant to what you are doing? I would have thought it may have some potential to assist a patient having to travel miles from where you are based to see someone like Dr Kinghorn or Dr Munday.

(Dr Ford) I think it is an excellent idea but it takes an enormous amount of resources. You have to have somebody at the other end who is not seeing 25 patients at the same time.

570. It could be used, as far as you are concerned?

(Dr Ford) Yes.

571. I was at a conference yesterday where we were looking at telehealth and it struck me also on the issue of the embarrassment side for patients avoiding having to sit in the kind of place in Manchester where you might even see a groups of MPs wandering around the clinic.

(Dr Ford) I have an example where, if the treatment for chlamydia changed, that would be kept up as a dialogue between the consultant and an e-group and it would be very helpful to have that in our area.

(Dr Munday) There is one particular problem in relation to GPs which has a training outcome. Patients with STDs do not go with a label saying, "I am a patient with an STD." They go with gynaecological symptoms and urological symptoms. Many people do not think STIs; they think gynaecology. A woman may turn up with some sort of minor gynaecological symptom and she is sent for a scan or she is booked into a gynae clinic in several weeks' time. The GP does not think: this is a 19 year old patient. She is on the pill. She must be sexually active. Let us rule out GUM problems first. There is a big educational issue there to make GPs and gynaecologists think in a slightly different way. If we could do that, that would help tremendously in a symptomatic patient. Screening is fine but there are a lot of patients who have symptoms who are not being appropriately diagnosed.

(Dr Kinghorn) The need for improved communications and the use of all the media available to us for that purpose is fine; also using the internet. I am sure there are many things that can be done. There is one big issue about teleconsultations and that is patient acceptability.

Dr Naysmith

572. This Committee has had quite a few representations about chlamydia recently and we are thinking about the possible expansion of chlamydia screening. What Dr Ford has just said is a real in to what we want to find out a bit more about because I am sure Dr Munday and Dr Kinghorn will want to reply to her suggestion that you are dismissing what you do in general practice as being not quite to the same standard as you do. What is the real answer about the sensitivity of the different tests in different places for chlamydia?

(Dr Kinghorn) There are two common tests. One is called enzyme immunovaso and in the Portsmouth studies it was found that it picked up between 50 and 75 per cent of the positive patients as compared with the molecular test. The molecular or nucleic acid gasification tests are more expensive but they will pick up more cases from those people who are screened and one can use samples such as urine or a swab somewhere near the relevant part in order to make a diagnosis. For us to be continuing with a suboptimal test is iniquitous. In Portsmouth, following the completion of their study -- and they had very strong evidence -- they had to go back to using the suboptimal test on the patients that they are looking after. That, to me, is wicked. It is a situation which prevails across the country. There should be no argument. The evidence from everywhere says very clearly that this test is so much better.

573. What proportion of the tests nowadays are the most accurate?

(Dr Kinghorn) No more than 30 per cent of the clinics in the country have the right test available to them. The majority of people who are presenting for screening are being screened by this suboptimal test.

574. Are you talking about GU clinics?

(Dr Kinghorn) Yes. In general practice, I would suggest that less than five per cent of GPs have this test available to them. We have that problem with chlamydia screening. Many of us who have been looking at chlamydia screening and talking about it for the past 25 years cannot believe how long it has taken to do the obvious. The obvious is that there needs to be use of the appropriate test with as wide a coverage as possible.

575. Why is it not happening?

(Ms Nicholson) Money.

576. Presumably clinics have control of their own budget once it has been given to them. If they think this is really important, why do they not use the most sensitive test?

(Dr Kinghorn) If you have a finite budget, if the test costs more, you reduce the number of practitioners. I often have to make a choice between treatment of patients, particularly with HIV, tests and people. We have indicated that people are so crucial to us in terms of developing these networks, but the argument in terms of chlamydia screening and the availability of these tests, although there would be an increase in costs, it must be cost effective to do it this way.

(Dr Ford) I would agree. Chlamydia is so often asymptomatic. In practice, I have to decide, if I am seeing somebody who is in a high risk group, do I offer no screening or screening or do I send them to my friendly consultant who I know has a three week waiting list. It is a choice that I should not have to make. I am making a choice about that woman's health and her future fertility. We have written to our PCT and said that it is professionally negligent that we cannot provide this. We have not had a response yet but they have said they are looking at it positively. Like Dr Kinghorn was saying, if you provide that, you have to take it out of somewhere else because it is a finite budget.

577. One of the issues this brings up is that if the more sensitive test was used more widely it would create a lot more pressure on the service which already is not dealing with matters well. It is not sensible use, is it?

(Dr Kinghorn) It is not the service that matters; it is the people that we are looking at. We are letting down people, young people in particular. Even when they have the courage to come and see us, we are offering a suboptimal test. That is the tragedy. It is a problem that the more screening that is done the more aware people are and we should see more people.

578. Since chlamydia is asymptomatic, you are going to be picking up lots of people who do not even know they have a sexually transmitted infection.

(Dr Kinghorn) A proportion of those people are going to go on to develop complications and tubal damage and will present for infertility treatment services in the future. There is the risk that they will transmit it to somebody else who will develop those complications quickly.

(Dr Ford) The two pilots for chlamydia in Portsmouth and The Wirral showed that you can do this very effectively in general practice. There was a good pick-up rate, good screening and good treatment. There is no point in screening for it if you do not do anything about it. It is a great sadness that of the new pilots none of those is based in primary care. The pilots did show that this is a perfect thing, if you have the right training and support. It can be done very effectively in primary care and it is a real sadness that none of those pilots is going to happen in primary care.

579. One of the consultants we spoke to in Manchester said they needed a national roll out for a chlamydia screening programme like a hole in the head. Is that a fair comment?

(Dr Munday) We need a chlamydia screening programme and we are going to have to cope with it, one way or another. We cannot deny patients the opportunity to be tested for the commonest sexually transmitted disease, which is preventable and which is going to affect their future reproductive health.

580. Do you think there is room for a lot more scope in general practice for this kind of thing?

(Dr Munday) I do. I would like to see screening much more widespread, not only in general practice but in family planning clinics and gynaecological services where, even now, chlamydia testing is not widespread before invasive procedures such as treating a cervix when people have abnormal cervical cells. Quite often, those are young people and they are not being screened for chlamydia before they have that invasive procedure done.

(Dr Ford) If we look at cervical screening and what has happened in primary care and general practice, there is a national cervical screening which did not happen before there were certain things put in place. We can rise to the challenge as long as those things are put in place and chlamydia would fit very nicely into the model that they use for cervical screening. I am not quite sure why that was not done. Most of the people who present to GUM services think they have a problem or have symptoms. People present to us every day and we can screen everybody if we have the resources but we can certainly screen high risk groups who may not know they have the infection.

Julia Drown

581. The fact that the better test is not used seems to indicate a failure of decision making somewhere in the NHS. I appreciate patients are not being well represented but can any of you indicate where exactly the problem lies? You point out that there will be savings in the gynaecological sector if you pick up chlamydia early, so is it that you, combined with gynaecological colleagues, say, "Yes, this should be a priority of the trust so that it gets on the trust board papers", amongst other things, or is it trust board members not taking responsibility for this or does it not even get that far?

(Dr Kinghorn) Undoubtedly, some of the problem must reside with doctors who are often not clear about what should be relatively simple messages. They may find themselves in a competitive situation over what happens within their respective services, particularly if you are in a situation where there are finite resources. In the current world, we have to discuss these issues not only within our trust but also with commissioners. It is very important that our commissioners should be receptive because they are going to be the referees within this particular process. It is not about squabbling doctors; it is about making the right sort of priorities. Since 1997, sexual health has been taking over the priorities. It was in Health of the Nation; there was a sexual health priority. Now, many commissioners believe it is only those priorities which matter.

582. In pure finance terms, for the commissioners it is even more relevant than the trust. If they can save money in gynaecology, you would expect them to be jumping at the chance to do so.

(Dr Ford) Is this not one topic that should be taken nationally? The HIV test is national. If you had an HIV test that picked up 60 per cent and one that was a little bit more expensive and picked up 99 per cent, which one would you do? It should not be something that comes down to the local PCT area.

583. At one level I would agree but at another level would you not expect the responsible managers throughout the health service to be able to make that common sense judgment themselves? Those same managers are the ones who complain about directive after directive after directive coming from the centre. Do we really need to have directives about using the best test, particularly when they are picking up serious infections that can lead the health service to spend more money in the future?

(Dr Ford) I think so, yes.

(Dr Kinghorn) Yes.

584. The government is talking about more devolution to trusts, not less!

(Dr Kinghorn) The argument is can you leave this to local decision making. For matters of public health, I argue you cannot. There will be some who will understand this but there will be others who do not and because we are dealing with transmittable disorders there has to be direction from the centre. Otherwise, the same problems that we are talking about today will continue. The worry that I have is that the country will pay happily for HIV testing. It will pay for end stage disease because that has always been done and the prevention of the expense for the future will be something which will not be seen so much as a priority.

(Mr Taylor) Locally, we have a sensitive test for chlamydia and in reality it does increase the number of people attending the service. If it is decided to make it a priority locally, in the next breath I get the GUM and HIV service saying, "We do not have enough capacity." That is because of finite resources. I take your point entirely. Yes, there will be a saving in some other service but the connection between HIV, STIs and gynaecological services does not always exist. The person who commissions one service does not necessarily commission the other. I agree with you. I am very happy to push that but the allocation that goes to the combined hospital trust is a big lump of money. It is not broken down and that is how it becomes quite difficult to say, "There will be a £50,000 saving there; therefore, let's transfer it over here." If only it were that simple, I can assure you that my health service colleagues would have done it by now. Do we want more directives in the NHS? If I say yes, my colleagues will kill me. If I say no, the patients will be very upset and angry and so will my clinical colleagues. The reality is that there need to be priorities set nationally for certain things. Some of those have to be around transmission of infections, which should not be up to local decision makers. Also, I do not necessarily think that people will automatically be happy to fund HIV treatment and care because there are a lot of people who are not. When I am trying to find money for HIV treatment and care, it is always a battle at a national level. The allocation process means we do not get the funding for at least a year after we have had to start paying for it. Therefore, local PCTs have to club together to try to find that money. If you are part of a health authority with a very large budget, it is slightly easier than if you are a PCT where the percentage you need to fund is very hard to find. It is not so simple.

585. It is certainly not simple for us as a Committee to hear that managers want fewer directives and targets and yet here we are, hearing quite the opposite. However, Jackie, are there any legal barriers or folklore barriers that stop nurses being able to be more active and take a bigger part in clinics? Your own clinic has nurses taking a full part and doing treatment and prescribing, presumably. Is that the case across the country?

(Ms Rogers) There are no legal barriers. It is about equipping them to do the job.

586. It is about skills training?

(Ms Rogers) Yes.

Julia Drown: It is not that we need another directive. Excellent.

Jim Dowd: I wonder whether a national chlamydia screening programme should be made a priority or can it wait?

Chairman: This is before the pilots are completed?

Jim Dowd

587. Yes.

(Dr Kinghorn) I would argue that it should be a priority. Any of us who have children above the age of 25 would argue that it should be a priority. The arguments for screening have been accepted by the National Screening Committee. The issues that are important are coverage and sensitivity of the test. We find it very difficult to understand why we are rolling out in dribs and drabs in this suboptimal way.

Julia Drown

588. Are the physical environment facilities across the country worse than the average NHS state? Is there a case for saying that conditions within GUM facilities should be a priority in terms of physical improvement of the environment and equipment?

(Dr Munday) There was a lot of improvement in the early 1990s. Many new buildings were constructed. In general, the state of GU medicine is probably not bad overall. There are possibly notable exceptions to that. The problem is capacity. The buildings which were constructed in the early 1990s were for workloads of the early 1990s, not for workloads today. We have real difficulty moving people through the clinics because we do not have enough clinic rooms. We do not have the physical space to move them around. We have looked at lots of models to try and facilitate movement, but we have a barrier because we do not have enough clinical rooms.

589. That would be worse in other specialties?

(Dr Munday) I am sure it is the same throughout clinics.

590. It would be worse in other specialties within your trust?

(Dr Munday) GU medicine is rather different because we do everything in one building. We do all our history taking, our examination, our investigations in one block. Out-patients departments, for example, are upgraded once every ten years or so. All specialties that use routine out-patients will get their routine upgrade every ten years. We are a bit outside that system and we would have to bid separately to get an upgrade outside the routine system.

(Ms Rogers) There is also an issue about integrated clinics because we are being encouraged now through the strategy to integrate sexual health. The idea is to have one centre in one town, for instance, where people can get a one-stop service. We can hardly cope with the physical problems that we have now with GU. If we start to push family planning and the other services through that same clinic building, it will be impossible.

(Mr Taylor) Jackie and I coincidentally work in the same part of the country, in an urbanised area, Brighton and Hove. The contraceptive service is provided by a different trust in a different part of the city, whereas the GUM service is somewhere else altogether. Trying to combine those two different services on one site there is not the room for or the money for. However, in relation to other parts of the county, they are integrated services more or less but the reality is that, although they are integrated, they may be sharing a building with somebody else. The queue out of the HIV/GUM/STI service goes right across another service. If you are worried about confidentiality, you do not want to be queuing in a different bit of the service as well.

591. There is not a clear message. There is a message saying that you need bigger facilities. You are an exceptional case and there are other pressures in the health service. What we have had in terms of evidence coming through and the question for you is: is this a pattern or not? Is the service being provided from Portakabins? Is that widespread? We had Wolverton Clinic in Kingston telling us they lacked sinks in some clinical rooms which seems pretty shocking. How much are these the exceptions or how much is this the rule that the GUM physical state in the health service is worse than others?

(Dr Kinghorn) Our specialist society did a survey in April 2001 and we reviewed all clinics within England to assess their needs. 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 per cent of clinics and there would be the problem of space. About 20 per cent are Portakabins and worse. Some of them have been in the health service for many years, even decades. We need to rebuild. There is a need for investment in IT. Many clinics are not hooked up to laboratories. They have not been included in the upgrades that have taken place. We have a tremendous problem with clinical records because we have to keep our records separately. Finding space for those records is an absolute nightmare. We would like to see a comprehensive review of all clinic facilities as a matter of urgency.

Mr Amess

592. The government's strategy for sexual health is an ambitious one and they want it implemented within two years. I think a specialist has described the £47.5 million that has been earmarked for this as paltry. I suspect we know how you are all going to answer this question but for the record how do you feel about this £47.5 million? Can it be done?

(Dr Kinghorn) We always welcome anything which is a start. We have a very ambitious target by 2007 of reducing the number of new cases of HIV by 25 per cent. We know that the cost benefit of preventing one case of HIV is somewhere between 0.5 and one million according to the strategy document. If we prevent 25 per cent of those that occurred last year, that is over 1,000 and the benefit on an annual basis is between half and £1 million. I am arguing that the price to implement the strategy properly may well be and is in excess of the 47.5 million which has been made available to us so far. The cost of not doing it is going to be far greater.

Dr Taylor

593. Can we turn to primary care? Whenever changes in the health service are made, it is always rather assumed that it is left to the GPs to pick up the tab and this is very much so in this service. You have given us an absolutely excellent paper which has outlined the problems and the solutions. Have you any clues about how the new GP contract is going to address the need for GPs to be taking on extra training and extra specialist services, not only in GUM but in other things as well?

(Dr Ford) We have been trying to find out what is going on with the GP contract. It is one area that is needing a central remit or whatever. The new GP contract is either going to change general practice completely or destroy it. I feel very positive about it but it is changing the way that we work. We are moving away from the shopkeeper on the corner to looking at needs assessment of a population and quality markers. It is a positive move but the core of what we provide is acute medicine and terminal care. Additional services, which are the bulk of general practice which would be vaccinations and management of chronic, relapsing conditions, asthma, diabetes and things like that, are things that we can opt into as general practitioners. From what we know at the moment, it looks as if the only thing that is going to be mentioned in the GP contract is contraception. We are not quite sure whether it is going to end up an addition or enhanced. If it ends up in enhanced or if sexual health ends up in enhanced, we are into a real difficult position. We have to get the sexual health strategy moving forward which is about seeing sexual health, not contraception, as a core function of general practice. It is wrong that if somebody goes into a GP or a family planning or contraceptive service and says, "I want contraception" that they do not get a risk assessment. We have to move away from seeing it as something special and different to the core of our function. If you can take a good sexual health history, you can pick up an enormous amount of other things about sexual wellbeing as well as sexually transmitted infections. In some way, we have to ensure that it is in the main bulk of the GP contract with quality standards because one of the other things being introduced in the contract is quality standards. I love general practice but it is very peculiar. Somebody said the only consistency of general practice is its inconsistency. The GP contract potentially can move that forward, but we need some standardisation in what is provided in primary care. We have talked about training and we need good screening and diagnostic facilities and we have to think about data collection. In primary care we do not collect data, particularly around STIs. Somebody mentioned partner notification. There is not any way that we can do partner notification in primary care. It depends, to me, on having a good clinical network and that potentially can happen. The move should be towards sexual health services rather than contraception here and GUM there, with primary care being in the centre, so that we know where we can get help when we need it.

Dr Taylor: That is most helpful. I hope your paper will be an integral part of our report.

Chairman

594. On the last point you made about attempting to have a wider sexual health arrangement, would you apply that to the way in which we separate GUM in an effort to try and make it more attractive for people to attend and less embarrassing? If we were to broaden the functions, would that be helpful in general terms?

(Dr Ford) Yes. If you are going somewhere about your sexual health, it does not necessarily mean you have one of those diseases. If you go and see your GP about anything, it is about looking at your sexual health if you want contraception. Contraception may be one thing. Screening may be another. We need to bring it all together. We need to work much more in partnership. Our local GUM clinic sends letters to one per cent. We send a lot of people there. I question that. Specialists need to support what we are doing and we need to be able to do what we are doing effectively.

Dr Taylor

595. You make the point that at present all prescriptions are charged except contraception. Is that a major problem to the people with STIs?

(Dr Ford) It is. If you go to a GUM clinic, you get your doxycycline and you do not have to pay. In general practice, you have to pay nearly £7 now, but it makes an enormous difference, particularly to young people. That has to change.

596. Going on to the commissioning of sexual health services, at several of our evidence gathering sessions we have been bothered about the responsibility of PCTs and I think one of you said they are thoroughly inexperienced at this. Can you give us a flavour of how this is progressing, not only in your area but if you have any ideas elsewhere? Are leads being appointed within all primary care trusts? How are they functioning?

(Mr Taylor) I do not think I am sufficiently qualified to comment on behalf of all PCTs across the country. Locally, there is a lead commissioner and that is myself. I commission services on behalf of East Sussex, Brighton and Hove. The other PCTs have agreed that that is what I will do on their behalf.

597. How many PCTs?

(Mr Taylor) There is one for Brighton and Hove and four for East Sussex.

598. You are commissioning for five PCTs?

(Mr Taylor) Yes. My colleague commissions for West Sussex and he commissions for five as well.

599. Do the other four feel in any way disadvantaged, as far as you know, your own PCT excluded?

(Ms Rogers) No.

(Mr Taylor) I am doing my best to spend a lot of time with my PCT colleagues across the county because each local PCT also has to have a lead sexual health and HIV person. Consequently, when I am trying to find a way into the local PCT, I would be that person. In Hastings, it is Jackie.

600. Even though a PCT is not commissioning itself, it has to have a lead officer?

(Mr Taylor) That is my understanding. It is not clear from the strategy itself or the directives coming from the Department of Health. What it means essentially is that those local PCT leads, whether they are a lead commissioner or whether they are linking into a lead commissioner, there is an issue around the variability of experience of those lead PCT commissioners, not in Jackie's case but in some of my colleagues' cases they may have a very large remit of other issues to deal with and sexual health and HIV are bolted on at the end of that list.

601. To the other members of the panel, have the PCTs all got their lead officers in place?

(Dr Munday) No.

(Mr Taylor) Ironically, the Department of Health wrote to the PCT in Brighton and Hove and said, "Who is your lead commissioner?" I wrote back and said, "You already know but you have obviously not got the list." They said, "It is very interesting because the Department of Health does not know all the lead PCT commissioners because they have not been told." Sometimes the information might not have reached them or it has reached them and they have not coordinated the list yet.

602. Frank Dobson told us that the Department of Health is an information free zone.

(Mr Taylor) I do not know what to say to that.

603. We have had a lot of talk about national service frameworks at all of our meetings because it is obvious those people without them feel desperately penalised and it is also obvious that you are not going to get one for years and years to come, or at least three. What is the answer to that? How do you raise your claims without having an NSF?

(Dr Kinghorn) I do not think we have time to wait for an NSF in three years' time. We have to do the job anyway. We need as much support as we can get from the government but it is very clear that we have to do a lot of work ourselves, working together. This is why doing it on a piecemeal basis, PCT by PCT, takes too long. We cannot wait for local priorities and local needs assessments to do this job.

604. This is where we come to in, absolutely hammering this home.

(Mr Taylor) There is an issue about lead consortia arrangements. You might have one PCT commissioning on behalf of a whole range of PCTs to share the financial risk around additional staff needed and so on and that, I suspect, is what will happen. A commissioning toolkit which identifies a whole set of options and priorities hopefully will become available before Christmas. I am hoping that it will because it is very key that we get the commission to talk it out as soon as possible or clinical colleagues and myself will find it very hard to identify how things are going to be commissioned and what process we should be following.

605. Are you talking about a larger group than five PCTs?

(Mr Taylor) Yes.

606. What sort of size?

(Mr Taylor) It will depend on the nature of the epidemiology in the area. If you have London, you are not necessarily going to want a new consortium arrangement for the whole of London. Already there are a number of consortia arrangements for south west London but in other parts of the country there seems to be a perception that nobody has sex outside of London and if you go outside the urban areas nothing much is happening. If you looking at lead consortia arrangements, they may well depend exactly on the size of the population you are dealing with and the epidemiology.

607. Strategic health authorities would be too big?

(Mr Taylor) Potentially; not necessarily.

Julia Drown

608. The British Association of Social Workers and the Special Interest Group on HIV and Sexual Health have suggested that general practice has not shown itself to be free of the prejudice about HIV. How real a danger is there that those accessing services in primary care will come across that prejudice, particularly for HIV positive men and women and for young teenagers who want to access sexual health services? Is it true that they would be to encounter prejudice than in specialist services?

(Dr Ford) I do not think that is true at all. We have disclosure and satisfaction rates between people and they have been done in a lot of places in London. Most HIV people do disclose their positivity to their general practitioner. They feel that they get a good service and there is a bit of a myth that you are always going to get a bad attitude. I know some of my colleagues have appalling attitudes, but that can happen in any area of medicine, not just in general practice. I think a lot of that comes from ignorance. If you are frightened about something you tend to be more ignorant. It comes back to training. Certainly in work we have done around drug dependency, if you actually get general practitioners to feel confident working with drug users---- It is easier to say "you are a dirty scumbag, stay away". It is not rocket science. In HIV care some of the medications are rocket science but actually the management of HIV is not rocket science and we can manage it. I think one issue that needs to be resolved that we have been banging on about from the college is actually around confidentiality and insurance. We are the only general practitioners in the world I think, certainly in Europe, who provide information to third parties. If you want to take out a mortgage, the mortgage company asks me for your information and I send it to them and they can send it to everybody else. I think that is a real problem that we need to address in general practice, and we are trying to address it, but it would be nice to have some help centrally to actually say that you cannot be an advocate for somebody as well as a whatever it is.

609. So what is the solution to that?

(Dr Ford) Because general practice groups do not want to lose funds, if you have a patient who wants a mortgage report then you send them to me, although I never do them. You could have GPs doing it but they would not be their registered GPs. It would solve it incredibly easily and everybody would be happy. I do not know why no-one has thought about it yet. General practice is inconsistent but we are improving with standardisation, with minimum standards of care, and certainly we have produced minimum standards of care around sexual health and HIV care from the college group that we hope will be sent out to all general practitioners.

(Mr Taylor) Just to echo that, we did some local surveys of Brighton and Hove around attitudes towards shared care arrangements between GUM services and the GP practice and the statistics seemed to indicate that the longer that you are HIV positive and the more you use your GP practice, unsurprisingly the happier you become about using the GP practice. The issue is almost about a perception of what the GP, the practice nurse or the receptionist is going to say or do. That is a very deep seated view and it is very hard to unpick it. Irrespective of whether insurance companies will identify whether somebody has had an HIV test or not, the perception is that is the case, so consequently it is a self-fulling prophecy. People will not generally go to their GP because they scared and that has nothing to do with the attitude of the GP necessarily, it is about, "If I disclose here then is my insurance ruined for the rest of my life?" It is a very, very difficult issue but it does not necessarily have to be, as my colleague just said. It is about being clear about expectations, being clear what the shared care arrangement is and making sure that in some circumstances where it is not working then the patient and/or the GP is not penalised but is helped to understand what should be happening.

610. It is about giving patients the confidence that they can have confidentiality and that information does not go any further?

(Mr Taylor) Yes.

Julia Drown: I know you want to come in, Marianne, but in responding would you also deal with the issue about anonymity because I would be interested in your perspective about whether you think patients would always prefer to go to a GUM clinic rather than discuss with their GP conditions that they might be embarrassed about?

Chairman

611. Can I ask a point I raised earlier, whether we ought to retitle or restructure the nature of these clinics to make it a wider group of patients who are being treated and, therefore, more acceptable to people?

(Ms Nicholson) I believe the North East did a survey on this and they found that although a good proportion of people were happy to have GUM and family planning services provided from their primary service, a lot of them, for both family planning and sexual health, wanted the anonymity of the separate clinic. I cannot see any reason why you cannot put the two of them together, which might be beneficial, but I do not know that that survey has been done. I wanted to point out that a lot of our members will not let their GPs know that they have a sexually transmitted disease. It may be that the GP would be perfectly comfortable with it but, as my colleague said, it is perceived that the GP will be critical or judgmental about it. Remember that sexual illnesses can be picked up outside of a marriage situation and the GP will usually be the GP for both the partners, so people have to have the ability to go to an anonymous service. I wanted to pick up on the point of the reports going to insurance companies and mortgage proposal forms. I had a chat this week with the spokesperson from the Association of British Insurers and they have been looking at new ways of getting the information that the insurance companies want without actually asking a question about sexual health in too broad a term. They agreed that the list was too long to say "excluding such illnesses", but equally that the list was too long to say "we only want to hear about those illnesses". The suggestion that we came up with would be if the committee would make a statement about the fact that it would be helpful if the insurance industry does not penalise people for getting STI check-ups, because that is the issue, that people who are taking care of their health and getting frequent annual MOTs have to declare this and this could penalise them, or they perceive that it would penalise them. Another way that this could be expressed that we came up with was insurance companies should find a better way of assessing the health risk to their clients from sexually transmitted diseases because that, after all, is what the insurance companies want. They do not actually care about the disease itself since most sexually transmitted diseases can actually be treated, it is an indicator of the general lifestyle that they are after, but they have not found a way of asking the lifestyle question without bringing in these other points.

Andy Burnham

612. Can I ask a couple of questions about, firstly, sexual health inequalities and then the voluntary sector. On health inequalities, am I right in thinking that some of the problems we have been describing today are not uniform across the country but the pressure on services tends to be focused on particular parts of the country? Just going on from that, is that partly due to the fact that there is a very strong link between social deprivation and all the problems we have been discussing, sexually transmitted infections, teenage pregnancies? Is it that link that we need to get underneath, as it were, and address? Does anybody have a view on that?

(Dr Kinghorn) Undoubtedly sexually transmitted diseases, unwanted teenage pregnancies, social deprivation, inequalities, these go together. The greatest pressures from sexually transmitted diseases have always been traditionally in the large urban areas. However, the pressures now, the pressures that we described earlier, are right the way across the country in urban and rural areas. I know of no clinics that have got any slack at the moment, the screams of anguish are being heard throughout the whole of the country. Dealing with the essence of your question, yes, we do have to realise that those who are from the most deprived communities are those with the greatest needs in terms of sexual health and it is very important for us, I think, to react in a different way. It is certainly the case that a centralised service may be more inaccessible for those people who live in the most deprived areas of the bigger towns and cities and for that reason our strategy for the future has to be maintaining that service but having outreach from that core facility in order to try and better meet those needs.

613. Is there any evidence that people are more likely not to be registered with a GP as well?

(Dr Kinghorn) Yes.

614. You are talking about people who are not likely to access health services?

(Dr Kinghorn) This is a major problem. To emphasise the point I was making earlier, there are many individuals who do not access other health services. The opportunity is now, it has to be immediate, we have to be able to respond to that need otherwise they will be forever lost to the service. This is particularly true of the young. We still see many individuals who do not access services elsewhere.

615. Dr Ford, you mentioned earlier about the Sexual Health Strategy being too narrowly focused. What would you like to see there to try and break this link between deprivation and sexual health? What kinds of things would you have wanted to have seen in that Strategy? What kind of approach would you have wanted?

(Dr Ford) That is a small question! If it had started with something more about the positive things around how sexual health is part of our whole well being and what other things can affect our well being in terms of deprivation and housing. I know that we cannot solve all of those but somehow putting it into a context rather than just ----

616. How you treat it?

(Dr Ford) Yes. Just going for the "let us treat it", you have not looked at the causes of it, so more around perhaps looking at the causes.

617. Is not part of the problem that that goes well beyond the remit of the NHS?

(Dr Ford) Absolutely, completely, yes.

(Mr Taylor) I think there are some lessons also to be learned from the Teenage Pregnancy Strategy which might be criticised on a whole set of different levels on which I am not intending to criticise it today. Quite clearly the Teenage Pregnancy Strategy identifies a whole set of people who need to be involved in discusions around teenage conceptions. The same issues apply post-18 as they do before 18. What is very interesting in the Teenage Pregnancy Strategy is the Partnership Board consists of a whole range of different organisations not just from the NHS but from the local authority, from the voluntary sector, from youth services and from a whole range of other settings and the reality is that the Sexual Health Strategy is actually a Sexual Ill-Health Strategy because it is targeting STI so we are looking at the end product of a whole set of social deprivation. Consequently we need to be looking more clearly at why people are taking choices in the first place so, yes, I would suggest that we might want to look at the Teenage Pregnancy Strategy and how that works. I am not saying it has been altogether successful but quite clearly the partnership arrangements involving education, involving youth services and urban regeneration funding and all the rest are more likely to tackle the issue than a Sexual Health Strategy per se focuses on STI and HIV transmission. That is not a criticisms of the strategy but it just needs to be broadened out a little bit. That is, I suspect, what PCTs will be having to do as part of looking after their local populations.

(Ms Rogers) I work in a recognised area of social deprivation so I have first-hand knowledge of how we are trying to manage. Certainly I think that Graham is right, the model of Teenage Pregnancy Unit has flagged up, and we are using, partnership. We are doing a great deal of partnership work and it has been very successful. At the moment we have got a teenage conception rate of 44 per cent higher, one of the highest in the country, and so we have been targeting young people particularly and we have been doing a lot of work from the clinic with youth services and primary care and education, and it works well because they are sign-posting to our department but, as I have already said, our department is a part-time department and so there is no core funding money. They are throwing us all these patients and quite rightly particularly young people are turning up, it is very successful, but we cannot manage the numbers we have so it falls down there.

618. So the basic approach may be good but it is the capacity of the system to deal with what it throws up.

(Ms Rogers) Yes.

(Dr Kinghorn) That which goes first when you are in a pressurised service is this sort of outreach and preventative work, and that is a major problem. All of us, to come back to what Dr Munday described before, have had to cutback on outreach and preventative work because of the pressure just to see patients. It is really quite key for the future, as is the involvement that was discussed before with teaching and training. Clinics have more than just a function of treating patients when they have problems.

(Dr Ford) Could I come back to your first question about why it is we are seeing pressures right throughout the community, and not just in deprived areas. I believe that is due to health-seeking behaviour amongst middle-class communities. Although the deprived areas are seeing people with very high levels of STIs we are seeing very high levels of demand in areas where people are actively seeking improved health care. That has been promoted by many of the women's magazines for example which are read by articulate, young adults and so they are going for their health checks. Many of those people do have chlamydia and other sexually transmitted infections, it is just the prevalence is lower and you have to screen more people to pick up the cases. Those people are just as entitled to have their chlamydia diagnosed as anyone else. We are seeing that sort of pressure on rural areas, for example, on non-inner city areas because of health-seeking demands. There is no doubt that the new health campaign which is coming on-stream I gather next week is going to exacerbate that situation.

Sandra Gidley

619. Now something slightly different. We have concentrated so far on STIs which according to our brief affects about ten per cent of the population. Sexual dysfunction actually affects a greater proportion of the population but attracts very little attention in the Sexual Health Strategy. Would anybody like to hazard a guess as to why they think that is?

(Dr Munday) I think sexual dysfunction in its widest sense is very closely linked to all the issues around sexual health. Many of the reasons why people acquire sexually transmitted infections relate to poor sexual relationships and sexual dysfunction is one of the many outcomes of poor relationships. One can see it as part of a sexual malaise within a relationship or within a community. I think erectile dysfunction, if that is what we are talking about, is the tip of the iceberg really. There is an enormous amount of sexual dysfunction which is under the surface and which we as clinicians in general practice and in GU medicine constantly see and we see the consequences of that. In women it is much more tenuous and difficult to identify because it tends to present with medical organic-type problems whereas in men it tends to present with pure erectile dysfunction and therefore attracts attention and is obviously a cost that can be costed in separately from other things. It is because of the cost which attaches to erectile dysfunction there has been some anxiety about it. But it is only a small part of the whole sexual dysfunction agenda which needs to be looked at, in my view anyway.

620. To come back to the question the Chairman has raised at intervals, would it help if all services were put together under one umbrella? Would that make it easier to deal with this problem rather than it being presented in different forms?

(Dr Kinghorn) I do not think any of use have any problem with the concept of services being co-located. The problem is that virtually every department in the country would need to be rebuilt under those circumstances and so there is a time problem and there is a funding problem. I think that what matters before that decision is made is the partnerships, the collaboration and the communication that has to be done. If we can make sure that a person is seen in all of the services that are necessary for that person within the same day or within a reasonable period of time, by good communication we can facilitate that particular pathway, that is okay. The worry that I have is that we are arguing for a model which exists in very few places at this present time and which as yet has not been evaluated. In theory it sounds correct, I would just like to ensure that we have more information about it before we all choose that particular path. I know the Department is looking at that at the moment. We also have to remember that some of the problems of sexual dysfunction tend to affect an older age group and one of the problems for younger people is they might not just see their sisters and brothers but their fathers, and in fact it could be an issue.

621. Okay, so you are saying older people may not want to access that sort of service. I think that is right. It depends what patients will tell us and Marianne was saying before that one size may not necessarily fit all and we have got to take advice from our local communities.

(Ms Rogers) Sexual dysfunction therapy is very time consuming and therefore very expensive. Most therapists will see a patient for an hour and they will contract with them to see them over a period of time so it is a very expensive service and it falls between two areas really. Some sexual health clinics have taken on therapists but it is almost a luxury and funding is the issue.

(Dr Ford) I was going to agree with that. It is almost like the syndrome of Cinderella. I feel I have got some skills in sexual health. My skills in sexual dysfunction are much more limited, very limited, and it was a situation where I would ask somebody, I would ask a man who can but actually in my area there is not anything. There is a therapist in the next PCT who has got about a year's waiting list so I have to try and muddle through with that person, and it is more older people but there are quite a lot of young people who come with quite a lot of problems. If you can deal with them then and there that is fine - and we quite crudely try to deal with it then and there - but if it is not dealt with it can become an increasing problem. It is the same as STIs and the resources around sexual dysfunction are almost non-existent really, certainly in my area.

622. This brings me on to my final question. If we talk purely about erectile dysfunction and how you can treat that, there are a lot of restrictions on the prescription of Viagra. There was a consultation exercise and the decision was taken not to widen the availability. Does that suggest to you that the Government really does regard this as the "Cinderella of Cinderellas" and it is not really a very important problem?

(Dr Ford) Viagra can be helpful but it is not helpful in everybody and so obviously it should be available to people that it can help, I think. But so often what would be wrong is that it became the solution to the wrong problem in a way. For a lot of men who do have dysfunction it is not about a tablet improving the situation, I was going to say "getting it up", but you need to look at why they are having that problem. Obviously if it is diabetes or a very physical problem they should have access to Viagra but it is not the panacea for everything and should not be used as that.

Chairman

623. Women are much happier than men talking about men's problems. I was going raise the issue of the evidence that we received where a witness suggested that a third of men suffer from some form of erectile dysfunction. What has struck me with this inquiry is the extent to which women have screening processes built in in a range of ways that men do not have. In my own area we have a Well Women Centre, the cervical screening programme, clinics that are giving contraceptive advice. What are your views on the way we might better target men, who by tradition are much more embarrassed about this area than women?

(Dr Kinghorn) Men certainly need to have assertiveness training. I smile about this because often a lot of training takes place with younger women but I think that there is an educational process that needs to take place in schools about health and about promoting health seeking behaviour. One of the places young men access health care is the GUM clinics for matters of sexual health because it is very important it at that stage. It is so important to get it right first time. If they have a positive experience when they are seeking health care at that time then that will be a positive influence for the future. Conversely, if they have a bad experience that is going to further delay when they have other events in their health care in the future. So those of us who are going to be the first point of call need to make sure that we provide a supportive service for men when they come of whatever age, but there needs to be more education in schools. You are quite right that men in general are far less comfortable in terms of dealing with most attitudes about their health but particularly about their sexual health. It terms of severity I often say to my medical students men will consider anything wrong with their nether regions to be the next to death in terms of importance.

(Dr Ford) There is a joke - or a serious saying - in general practice that if any young man presents with acne he is presenting around sex and if you do not ask about sex then you have lost a real opportunity.

624. I must go away and think about that one. Do any of my colleagues have any further questions or any burning points?

(Dr Munday) I was going to make the comment that it is extraordinarily difficult to reach men, particularly men without symptoms, because they do not access health care from the moment they have their last vaccination to the time they have their first coronary, and that is an enormous period of time.

Jim Dowd

625. Saving the nation money.

(Dr Munday) Absolutely, at least in the short term.

Chairman: Can I thank our witnesses for what has been an extremely helpful session. We are most grateful for the written evidence and the comments you have given us today. We have learned a great deal in this inquiry and we appreciate your help. Thank you.