THURSDAY 23 JANUARY 2003

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Members present:

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

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Memorandum submitted by Department of Health

Examination of Witnesses

MS HAZEL BLEARS, a Member of the House, Under-Secretary of State for Public Health, and MR STEPHEN TWIGG, Under-Secretary of State, Department for Education and Skills, examined.

Chairman

Welcome to this session of the Committee. Can I particularly welcome you, Minister, to your first appearance before the Committee. We are pleased to see you. Thank you for your cooperation with this inquiry. Stephen Twigg will be joining us at half past eleven, so the first hour of the Committee will be related primarily to Health Department responsibilities. Could you briefly introduce yourself to the Committee.

(Ms Blears) I am delighted to be here, Chairman. I am Hazel Blears. I am the Government's Public Health Minister, and I have responsibility for the implementation of the Sexual Health and HIV strategy.

Can I begin by saying that the whole question of sexual health is something that is not frequently raised with MPs. The whole Committee has been, frankly, shocked and appalled by some of the evidence that we have received, that is written evidence, oral evidence and what we have seen when we have been visiting various parts of the country. Among the evidence we have received, Sarah Gill, who was a GU physician at Paddington, told us, and I quote, "I have never seen the extraordinary intensity of patient numbers as witnessed in the last six months or so. The Department is like a war zone/A&E. There is a queue of patients up to 40 deep most mornings." She said, "Nobody wants to end up in a clap clinic, let alone when you have to wait up to four hours to discuss your most intimate of problems with a harassed doctor, who is still worrying about the last patient hurrying out of the room in a bid to try to relieve the already heaving waiting room." A doctor in Chester told us that he had never seen a service become so "demoralised and overwhelmed, with staff pushed to the limits." We have figures of a huge increase in workload and diagnoses. Frankly, the whole sexual health service appears to be a shambles. Would you agree?

(Ms Blears) I would not agree that it is a shambles. I would agree that for many years the whole field of sexual health has not been a priority. Some people describe it as a Cinderella service. People working in the field have felt that, I know, for very many years. I have had an opportunity to read some of the evidence that you have taken as a Committee, and I know that you have been out to visit. I too have been out to visit since I took responsibility for this area. I have looked at GU clinics in Manchester Royal Infirmary, in Hope Hospital, I have been up to a one-stop shop up in Hull, and I have looked at some of the facilities in London as well, and I have seen for myself the pressure that staff are operating under. It is absolutely undeniable that we have had a huge increase in sexually transmitted infections since 1995. We have also seen a massive rise particularly in chlamydia and in HIV, and that is absolutely one of the main drivers for why we now have the first ever sexual health strategy in government. For me, it is clear why that strategy was needed, why the action plan is so important, and why the extra funding that we are putting in place, both in terms of pump priming from central government but also, even more importantly, the extra funding from primary care trusts through their mainstream budgets to modernise, improve, re-engineer and almost re-energise the whole of the sexual health field, is so important. We have put £5 million into GU services in this last year, which we do think will make an appreciable difference in trying to attack some of the waiting times, which have gone up from an average five- to six-day wait for an appointment to 12-14 days, and I know it is much worse in some parts of the country where they are under particular stress. Long waits for urgent appointments in this particular field not only affect the patients, but the evidence is that an untreated sexual infection can lead to the infection of between one and four other partners whilst a person is waiting for treatment, so there is a real public health imperative here as well. I entirely acknowledge the pressures that people are under, but we are on the case, and that is a very real reason for the strategy and making sure the strategy works in practice, on the ground.

The Department, way back in 1988, had the Monks Report, which you are probably aware of, which recommended that patients should be seen on the day that they present, or on the next occasion that the clinic is open. We went to Manchester and took evidence in your own part of the world - as you know, because I told you about the visit - and we were told there that waits of up to six or eight weeks were not uncommon. What is very apparent is that during this period of time people who are aware they have a problem continue to have sex. The reason we perhaps have this shocking and worrying increase in STIs and STDs is a consequence of people who try to access help being effectively turned away. I accept that the Government has developed a strategy, but this problem is surely so urgent that a strategy that is looking at a ten-year programme is all well and good and is going in the right direction, and we would all accept that, but it is not enough. These professionals are frankly crying out for help, and they are not getting that help. They do not see any future, so we have difficulties with recruitment. Do you not feel there is a need to act much more urgently than apparently has been the case in recent times?

(Ms Blears) I think it is like other issues that we are facing in the Health Service. There needs to be almost a twin-track approach: there needs to be urgent, immediate action to deal with the problems that are facing us today, but there also need to be long-term strategies for the whole of the Service. This strategy, like the NHS Plan, is a ten-year strategy, and I think that is right, because there are two drivers here. One is about immediate access to services, to get treatment, to stop re-infection, to stop infection spreading more widely throughout the community, but the other issue that we all struggle with is changing people's behaviour. I think you have had evidence from the lifestyle surveys that people are having more partners, they are having more concurrent partners, and that people's sexual behaviour in the last couple of decades has changed quite markedly. Even though there is an increase in condom use, that is counteracted by the increase in partners and in the number of concurrent partners. We have a real lifestyle issue here, and changing behaviour is a more long-term challenge than immediate services. I entirely agree; we need to do both; it is not either/or. It is about getting the money in to release the pressure on those services, to get waiting times down, but it is also about having that long-term campaign. A third thing I would throw into the pot is that these services have not had the attention that they have deserved in the past. Many of them are still stuck in the clinic at the back of the hospital, without the kind of profile or importance in the rest of the service, and bringing that service into the 21^st century in terms of much more primary care is important. In the strategy we set out a level one, two and three hierarchy of services, and we envisage many more of certain of the level one services - the diagnosis, the interview, the partner chase, all of that - to be done in the primary care setting. That, I feel, will also help to address some of the work force issues, because in the past there has been a tradition that everything has happened in hospital and everything has happened under the aegis of consultants. Consultants are important in this field, but equally so are nurses, health care assistants and health advisers. Getting that skill mix in there and changing the work force, again, is not a matter that can be done overnight. Right across the Health Service we are working with the work force confederations to get that skill mix, to get much more nurse-led clinics, much more nurse-led activity here, and trying to recruit people into the field. But again, you only recruit people into the field if they feel it is an exciting and worthwhile place to have their career. There are a number of steps we can take: immediate action, injection of funds to get the waiting lists down, recruiting more consultants, which we are doing, getting the skill mix in for the nurses, and then doing the long-term behaviour change work, which we are doing with our communications campaigns and with our information out there in the community, and finally, working, absolutely crucially, with the voluntary sector in this field. You will have found out from your evidence that it is not just the NHS, but those voluntary organisations which are fundamentally important to us.

One of the difficulties about your role in government is that, although you are a Health Minister, your remit is far beyond the role of the Department of Health. It goes right across government. I made the point at the outset that I think some of us have been shocked by what we have picked up. One of the problems is that politicians are not aware of the extent of difficulties. I do not use the word "crisis" lightly, but I think we have a crisis in this area of policy, from what we have seen and the evidence that we have taken. Do you feel that there is sufficient awareness across government, cross-departmentally, among other departments which have a role to play, of the seriousness of the situation that we are facing in this area of health at the present time? There are many wider issues that relate to this, not least the media presentation of sex to young people and children, and there is certainly the sex education issue, which we will talk about. Do you feel there is sufficient awareness of the urgency of dealing with this across government, and at the very top levels in government?

(Ms Blears) You raise a very important point in relation to many of the areas that I deal with, whether it is health inequality, trying to get every government department on board to address these issues. Similarly with alcohol. I am currently the minister responsible for the Government's alcohol project, and again, with DCMS, Home Office, everybody else has a role to play. I know that in drawing up this sexual health strategy those departments were fully engaged in realising just how important this issue is to all of us. This is an issue about our communities, about society, about behaviour, and it is about the future of young people as well. Therefore, the Department of Health has played a big role in the sexual relationships education field. That is something new for me, that the Department of Health would have a big input into making sure that that sex and relationships education was well-founded, evidence-based, good, accurate, credible information, and therefore I am working very closely with my colleagues across government to make sure that this issue, as with other public health issues, impinges on all of our policy responsibilities. I think increasingly in government we are recognising the cross-cutting nature of the policy issues that we are addressing. They do not fit neatly into departmental responsibilities, and it is incumbent on us, as politicians, to get out of our silos and recognise that these are issues for all of our communities. I genuinely do think there is an acknowledgement and recognition of the fundamental importance of sexual health and these other issues that particularly affect young people and how important they are.

Mr Burns

Minister, you gave a very comprehensive review to the Chairman, and you came up with some ideas for the future of what must happen, with more staff, greater concentration of effort, greater coordination, etc. I wanted to go back to the specifics. Being the MP for Salford, of course, you will be familiar with what is going on in your own area of Manchester. As the Chairman mentioned, the ideal is for an individual to see a doctor or relevant medical practitioner on the day that they present themselves, or if that is physically not possible, on the next day that the clinic or outlet is open. The evidence is that it is possibly six weeks, which is 41 days, later. I assume that you were aware of those statistics for Manchester? You nod, so I take that as an affirmative. What have you been doing since learning of that to find out what is going on in Manchester, and what can specifically be done to improve the situation for potential patients in Manchester, who ought not to have to wait 41-42 days to see someone, but who ought to have the service that the guidelines suggest they should, ie the day they present themselves or the next day that the clinic is open?

(Ms Blears) In my original answer I acknowledged that average waiting times had gone up from five to six days to 12-14 days, but in parts of the country, including places like Manchester, they are much longer than that, and therefore it is a priority to try and get them down. I think that requires a number of different kinds of action, which have already started to be implemented. The first one is the immediate injection of extra cash, and that is why we put the £5 million in immediately to try and ease the pressure.

Is the £5 million for Manchester or nationwide?

(Ms Blears) That was nationwide, from central funds.

In what way will Manchester benefit from that?

(Ms Blears) I do not have the precise figure for Manchester, but it was allocated on the basis of the prevalence in those areas, so it was allocated to those areas where the pressure was the greatest. I can certainly supply the Committee with the breakdown of those areas. That was an immediate injection of cash. The second thing is that we wanted to make sure that every primary care trust allocated somebody to be responsible for sexual health, because that has not been the case in the past. We now have 286 PCTs who have designated a particular sexual health lead. We have 18 outstanding, and we are chasing them to make sure that we get them, so that somebody at primary care trust level has personal responsibility for monitoring the situation and recommending improvements. In places like Manchester, which do have significant pressure, the need to redesign the service is even more pressing than in places which are not operating under that pressure, and therefore getting more primary care clinics, getting more nurse-led operations, and also new technology will be important. I went to Manchester Royal Infirmary to look at their clinic, and I think one of the problems they were struggling with was that they did not have a computer system that enabled them to track the contacts of the people that had come in for diagnosis. Clearly, that is a key issue in order to reduce the spread of infection. I cannot dictate to the primary care trusts what their priorities should be, but from my visit, introducing new technology - or even relatively old technology - so people can get computerised systems would be a top priority for me.

Is there not going to be a problem there, despite the best intentions of the Health Service or politicians, in that a proportion of patients will possibly not actually give their name or accurate address? Because of the nature of their medical condition they do not actually want to be contacted. They want the treatment, not unreasonably, but they do not want follow-up contact, except by them presenting themselves at the clinic.

(Ms Blears) I think that will always be an issue in the area of sexual health. Confidentiality is absolutely fundamental to people trusting the system, that they know they can get treatment and they are not going to be unduly exposed to their friends, their neighbours, their community, and that trust is very important. Obviously, there are protocols in place for confidentiality, about access to information. There I think the role of the health care adviser is crucial, because that is somebody who perhaps can take the time, whereas consultant will be heavily pressed to get the patients through. If you have a health care adviser, they can sit down with somebody and talk it through, talk through the implications, and maybe explain some of the public health issues to people. My experience is that if these issues are properly talked through and reassurance given, people are much more likely to want to cooperate and give us that vital tracing information so that we can get other people treated. I am not saying for one moment that we will get 100 per cent accurate information, but the more we can do to maximise it, the better for the whole community.

Chairman

When you went to Manchester, which, as you know, the Committee have been to, to the Royal Infirmary, I seem to recall being very struck by the fact that in the examination rooms the doctors do not even have sinks to wash their hands. Did you notice that?

(Ms Blears) I did not notice that personally. I went on a very brief visit. It was at the end of a day of presentations from the consultants to me, so it was a relatively brief visit, but I was not aware of that.

One of the worries we have is the facilities we have seen. We are going to the West country, where we understand some of the problems are even worse than in Manchester. The physical facilities are, frankly, below what could be described even as basic. To conduct an examination of the kind that would be conducted when there is not even a sink in the examination room, I find frankly amazing.

(Ms Blears) Can I just comment on that? I think that is right. In some parts of the country, because it has been a Cinderella service, and stuck at the back of the hospital, that is the case, but when I went to visit Hull, and looked at their new facility, which is a one-stop shop, where we are currently calling for pilots to take place, they have a range of community facilities: a drop-in clinic, so people can just turn up; it is right in the centre of town, so it is very accessible; and they have a multidisciplinary team working together there, sharing ideas. That is the other end of the spectrum, where there has been significant investment and it is a good service. Perhaps that gives a flavour of the variation that there is in services across the country.

John Austin

On the one-stop shop, what is the timetable for the evaluation of its effectiveness?

(Ms Blears) At the moment we are just calling for bids for the models. The one in Hull has gone ahead on its own initiative. Nationally, we are right at the beginning of that process in terms of looking at the models that we want, and I am not sure if Hull are undergoing their own evaluation, or if that is simply a policy they have adopted as a local community. I can certainly let you have the timetable for the evaluation of the different models that we want to test out for a more community-based kind of service.

Dr Taylor

I wanted to pick up two things you said, Minister. PCT leads: in counties where PCTs have joined together to commission sexual health services, does each of the PCTs still have a lead, or do they count the lead in the commissioning PCT as the lead for the whole area?

(Ms Blears) As far as I am aware, we have asked each PCT to nominate a lead person, and I think that is important, because they are commissioning for their residents. But obviously we have consortia arrangements, particularly for specialised services, for example, for HIV services, which can be very specialised, and it is important that PCTs come together. But I would expect somebody in each PCT to take personal responsibility for developing services in their community, because some of the services are very community-based: contraceptive services really should be all over. So you have a hierarchy of services in sexual health, some very specialised, some fairly straightforward, and there ought to be somebody in each PCT with responsibility for that.

Going back to waiting times, we have heard in several places that they have found an answer, because if people were waiting for six weeks, or even four weeks, the number that did not attend, the DNAs, was very high. So they have organised a system where the clients ring up literally the day before the clinic and that clinic is full after half an hour, but to my amazement, when we talked to young people last week, they welcomed that sort of arrangement. Is this something that you would push nationally? Have you a view on this?

(Ms Blears) I have talked to some of the practitioners who have been developing similar schemes, whereby they ring people up the day before and slot them in or try and make arrangements in that way, and I think we have a lot to learn from different examples of good practice across the country. One of the things the NHS struggles with is spreading that good practice, as I am sure every, single one of you has experienced, and therefore perhaps having a system where in developing the strategy, we can learn from that good practice, because again, because of the confidentiality issues as raised by Mr Burns, it can be that we have a large number of appointments that are not kept. We have a lot to learn from those examples of good practice, yes.

Sandra Gidley

You mentioned Hull, which is bright, shiny and new and what we all ought to aspire to, but that is a one-off. I know you have read some of the evidence, but I do not know if you are aware of a statement made by Dr Kinghorn, who said that their society had done a survey in April 2001 and reviewed all the clinics within England, and I quote: "We were looking at the question of accessibility, acceptability and effectiveness, and whether that was compromised by inadequate premises. Refurbishments and extensions were probably needed for about 80 per cent of clinics, and there would be the problem of space. About 20 per cent are Portacabins and worse. Some of them have been in the Health Service for many years, even decades." Is that really good enough?

(Ms Blears) I do not think it is good enough. The very reason that we have the strategy, the very reason that this important inquiry is taking place is because sexual health services have not been a priority for many, many years. I think that would be all of our personal and professional experience, and therefore there is a need to not just invest in physical facilities, although that is very important, but also to give the whole profession the sense that this is a very important area for people to be operating in. I entirely acknowledge that we have a long way to go, but for us to be saying from the centre that by having a strategy, this is a priority for Government, the first ever; by having an action plan, there is a focus on it; by saying you have to have a PCT lead in every single community, that makes it an important thing for the Health Service to do. I should think that many of the clinicians and many of the people who work tirelessly, day in, day out, sometimes thanklessly in this area, would be pleased that at long last there is a focus on their area, which means that when they are battling for funds locally, they can point to the fact that the Government thinks this is a priority.

Would you like to bet on when this will improve, and when we will have only 20 per cent needing refurbishment? Would you like to give us a date?

(Ms Blears) I am not a betting person, but what I can say is, like the rest of the NHS, we have done a lot, there is a long way to go, but I think things are moving in the right direction. In sexual health too over the next few years - it is a ten-year strategy - we will see significant improvements in the physical fabric. We have to remember, we have the biggest hospital building programme that we have ever known in the NHS, and it is not just hospitals but primary care centres and one-stop shops that are going up now in communities. Sexual health, like the rest of the National Health Service, has an important role to play, and should have its place in some of those new facilities.

I wish I shared your optimism, Minister. If I can just pick you up on one other thing you said, you commented that what could happen in clinics, or maybe what did happen, was that there were people there who could spend time discussing lifestyle issues and all the rest of it. My experience when I spoke to people in Manchester and speaking to other professionals was that even those people were rushed and did not have the time to do that job properly, and there was a feeling that they were taking a sticking plaster approach, sorting out the problem, and sending people away without the information you are describing. What are you going to do to ensure that that part of the service really does happen and it is not as squeezed as the rest of it?

(Ms Blears) I think it has to be acknowledged that those services are just as important as the medical service that is provided, that this is a proper balance, and that this is not just a medical problem. It is about lifestyle, it is about contacts, it is about tracing and it is about behaviour. That brings me back to the skill mix issues, having more nurse-led clinics, where people do operate in a different way, where they do have time to sit down and talk through these issues. Already quite a lot of information is given out in my experience: health promotion literature, advice on lifestyle, advice on how to prevent sexually transmitted infections. I would not underestimate the amount of health promotion work that does go on. I acknowledge the pressures that there are on staff, but my experience is that people do engage in this kind of discussion, and yes, we need more capacity in the sector, as we need more capacity right across the NHS, and that is why, over the next three years, the PCTs are getting a significant increase in funding, and we are saying that our central funding, the £47.5 million, is really pump priming, and we expect significant investment to be made at PCT level in making all of these services improve.

John Austin

We have talked about Manchester, which may be set down as an extreme example and, like the problems in Brighton and parts of London, attributable partly to the significant increase in syphilis, but the general evidence across the country is that in one-third of areas there is a wait of three weeks or more. Do you anticipate that the average waiting times will come down by the end of the y ear, and if not, what will your assessment be?

(Ms Blears) I think I would be disappointed if we did not see some of the very long waiting times begin to come down as a result of the immediate injection of the £5 million, because I do think that that ought to go some way to reducing some of those more extreme pressures. But as I said before, this is a long-term strategy as well, and if you look at some of the figures, the way in which the sexually transmitted infections have been going up astronomically since 1995, this is a problem for all of us in society. If we stayed static, I would hope to see the £5 million make a real impact on those waiting lists, but equally if the figures started to go up exponentially again, we would be coping with yet another increase. I am a little reassured in that the rate of increase of sexually transmitted infections appears to be slowing down in the very latest figures that we have for this year. Those are the 2001 figures. We do not yet have the 2002 figures. But the rate of increase appears to be slowing down, so in those circumstances, I would hope that the immediate injection of cash would have a fairly significant effect, but that immediate injection of cash has to be linked with investment from the PCTs starting to come on stream, so that we can begin to see a bigger investment at local level as well. We are going to develop a waiting times indicator that we will be able to monitor, so I would be able to provide some further information when we see the effect of that investment on those waiting times. We are determined to monitor this, because in public health terms, as I say, it has quite a dramatic impact.

Is that £5 million injection of cash within the £47.5 million or is that additional to it?

(Ms Blears) No, that is within the £47.5 million. If I can give you the figures, in the first year of the strategy, 2000-01, it was £5.5 million; in 2001-02 £14 million. No, that is 2002-03. In the next year I think £28 million, which comes to the £47.5 million all together.

The £47.5 million is for the first two years of the ten-year strategy?

(Ms Blears) Yes. It is the three years. That is what was promised when we launched the strategy, that it would be backed by £47.5 million.

You are aware presumably that in the evidence we have had from those working in the field this is regarded as paltry and, one witness said, was perceived with ridicule. How would you react to that?

(Ms Blears) I would be disappointed if it was received with ridicule, because I think it has been well thought through, and it is the case that this is central money, designed to pump prime change, to act as a catalyst for redesigning services, to go into places, to do some pilots, to look at different ways of operating, and when they prove their worth, to have those pilots picked up by mainstream funding. I think that is a proper role for central pots of money. I do not think it is proper for central money to run local services for ever and a day, and the whole thrust of shifting the balance of power is to get the NHS's budget out at the front line with the PCTS so that they are making commissioning decisions in the interests of their communities. I think a good role for central government pots is to bring together the good practice, as Dr Taylor has talked about, and then say, "How can we drive that across the service?" If people are under the impression that this £47.5 million is all there is, then I would sympathise with their view, but this is about unlocking and releasing some of the extra funds that we have put down through the service by the biggest increase we have ever known.

I would certainly welcome the strategy and the emphasis that you put on it. I think most of us would recognise that the problems that we face are both in increasing incidence and what you refer to as a historic under-funding of the service. Whatever the Government may do - and you say this is pump-priming money - you have referred to the historic under-funding and set out some of the reasons why that under-funding may have existed. What has changed, in your view, which will ensure that those previous pressures that have led to an under-funding of this service do not continue and this does receive the priority and at a local level that perhaps you and I would like it to receive?

(Ms Blears) There are a number of things that we are developing and putting in place which will, I hope, make this an important issue for primary care trusts to take into account when they are planning their spending. There is, first of all, the fact that we have asked for a person to be identified, so there is somebody that everybody can look to whose job it is to make this happen in communities. Secondly, we are developing some much more detailed monitoring through the AIDS Control Act, in terms of spending around HIV prevention and treatment, because again, I think there was a real worry in the HIV sector that when we removed ring-fencing, the money would somehow disappear.

There still is.

(Ms Blears) Indeed. I think I can tell the Committee that we have done a brief survey, a sample of a range of authorities, urban and rural, in terms of the money that has been invested in HIV work, both prevention and treatment, and certainly the information from that sample survey is that people have kept up to the levels that they were funding, and in some cases have actually spent a little bit more, so we are reassured to some extent by that. But we are developing a monitoring system through the AIDS Control Act which will give us more detail about where the money is actually being spent, and importantly, rather than just the money, we will be concentrating on the outcomes to see what difference it has made to patients and to communities, because sometimes it is quite easy just to put the figure in and say, "Yes, we spent that," but it is important for government to be able to see how it was spent and what effect it had. I think it is important to develop those issues too. The third thing I would say is that sexual health is certainly included in the Inequalities Framework, in the Planning and Priorities Framework, for the NHS, and there is nothing more important to the Government than tackling health inequalities, and therefore that again will aid people at local level to make this an important area of work by saying that it contributes to our push on inequalities. If you look at the distribution of sexual health services, and the people who suffer most from sexual diseases and problems, it tends to be young people, many people in black and ethnic minority communities, where rates of gonorrhea and other sexually transmitted infections are much, much higher, and their services in some cases are much poorer. So in terms of the Inequalities Framework, there will be a real drive on sexual health as well.

John Austin: We may come on to the question of the removal of ring-fencing later, because I think what you have said is not in line with the evidence we have from, say, Terrence Higgins, but perhaps we can address that later.

Chairman

Minister, you talked about looking at the impact of additional investment, the strategy, and how the investment is affecting this area of policy. Looking at it the other way round, one of the things that you can frequently see in health policy is that if you invest a small amount of money now, it saves you a much bigger sum of money later on. Have you within the Department done any calculations on the way the lack of resourcing of this area is leading to the inability to treat people and consequent further infection and consequent more costly treatment at the time the individual actually gets treatment? HIV is probably the best example, but it is the case with other problems as well that if you leave it longer, it costs you more. Is that a calculation that you have done? It is certainly something that we have picked up in evidence that is very worrying.

(Ms Blears) I am not aware of any specific calculations on that.

Would you accept the general argument?

(Ms Blears) Right across the range of clinical conditions, early diagnosis, screening, early effective treatment is important, and as Public Health Minister, I absolutely fervently believe that investment in prevention is a good investment for the whole of the Health Service.

Yes, but the point I am making is that with this in particular, it is not just one person that is suffering; it is others who are also suffering as a consequence of the lack of treatment of the first person, who is turned away.

(Ms Blears) Indeed. What I would point to is that the development of the chlamydia screening pilots - and I am sure Members will want to press me on those issues - is an example of how much we do recognise that, that being able to identify people at an early stage, and get relatively simple treatment, for example for chlamydia, where we can clear up the infection in a pretty straightforward way, not only is good for the individual, but it also saves us the money later on in terms of the really serious effects of chlamydia, ectopic pregnancy, etc. That would be a very, very good use of our funds. We are already beginning to think in that way. I have a couple of figures here which might be helpful, that the prevention of unplanned pregnancy by contraception services probably saves the NHS over £2.5 billion a year; the average lifetime cost for an HIV positive individual is calculated to be between £135,000 and £181,000, and there have been some estimates that preventing a single transmission of HIV could save us between half a million and a million pounds, which is a stunning figure, and I think illustrates the important point that you are making.

Chairman: It just strikes me that if you were, as you do, bargaining with the Treasury about your future budgets, you have some pretty strong evidence here that some additional investment would save the Treasury a lot of money in the long term.

Dr Taylor

Can we move on to consultants? I know you have talked about skill mix, and I am sure we all welcome extension of nursing duties and other professionals and the part they can play, but specifically asking about consultants, in some of the places we have been to the ratio has been 1:300,000, in my own county it is 1:270,000, yet the Royal College of Physicians recommends a figure of 1:119,000. Do you think that is realistic? Do you think they are in a bargaining position, aiming at a very good figure and hoping for something better? What is your view about the level that we should have?

(Ms Blears) Obviously, we need to get more consultants in the specialty, as we do right across the board for consultants. We have commitments and plans to do that. I understand that we are likely over the next two years to get an increase of 35 consultants in this field. At the moment there are 275 consultants operating here, and so an increase of 35 is a significant increase, and that is a net increase, having taken into account retirements as well.

Does that take into consideration the SPRs in training? We gather there are far more SPRs in training than there are jobs available. Will that match that number?

(Ms Blears) I am not aware of the detail on that matter, Dr Taylor. My information is that the plan is to get 35 extra consultants into the field, and I think there are a number of extra Specialist Registrars as well coming on stream for us. So there is a significant increase in this field.

Dr Taylor: I think there is something like 30 SPRs each year achieving their training.

Julia Drown: There is an output of consultants of about 30 a year, but we also have around 70 doctors that complete specialist training in GU medicine in this year, 2002-03.

Dr Taylor

So it looks as if there are more who are going to complete training than there are going to be jobs for, which deserves looking into, at any rate.

(Ms Blears) As far as I am aware, there are ongoing discussions with the Royal College of Physicians about making sure that we have enough consultants in this specialty, that we are training enough consultants, and clearly that there will be sufficient roles for them to undertake. I know this issue is being discussed by the National Workforce Development Board, the workforce people who are out there, together with the College, and it is important if people want to go into this field, who have a real enthusiasm for it - because it is one of those areas where you do need a real commitment to work - that we make the most of their skills. I am not aware - certainly it has not been raised with me - of the possibility of more people training than there are going to be jobs for. It is almost the reverse; we do need more consultants working in this field, together with more nurses and more health care assistants.

The other figures we have been given are that 25 consultants in the specialty are still single-handed, which is fearfully difficult, and that something like 30 per cent of the clinics only manage for three days or less in the week.

(Ms Blears) Can I comment on the single-handed consultants, because I think it is an important point? It is not good for anybody to be working in isolation. It is not good for them, and it is not good for the patients, and therefore we are really concerned to try and set up some clinical networks so that some of the consultants can work more closely together, learn from each other, make sure their training is right up to date, and give each other some support in the way that they are working as well. So it is quite a priority to get those clinical networks in place for the single-handed consultants.

We have seen some of those. Did you say a commitment to 35 new consultants?

(Ms Blears) Yes.

Where is the funding coming from for those posts?

(Ms Blears) As I say, the funding that we have put into the GU service is the -

So it is money that is already supposed to be in the service? Is it out of the £47.5 million?

(Ms Blears) Those new consultants who are coming through by 2004 will already be in training and will already be funded.

So the money is there?

(Ms Blears) Yes. That is my understanding.

Chairman

If you find out that is not the case, perhaps you will drop us a line.

(Ms Blears) I will get back to you immediately. I would not want anything on the record that was not absolutely correct. That is my understanding. They are coming through by 2004, so that is imminent.

Julia Drown

You spoke a while ago about the costs you can save by preventing just one HIV case. Has the Department a view on the campaign by the Safer Needles network that say that if all NHS trusts actually used safer needles, you would prevent needle-stick injuries, and therefore the huge worry of staff when they might have picked up HIV, and also, obviously, if the case occurs in the NHS, the extra cost to the NHS and also the effect on morale of that member of staff and everyone around? Has the Department looked at that to consider whether there should be yet another central directive to say that all trusts should be using safer needles? Some trusts in the country are, but only a very small proportion.

(Ms Blears) I personally have not seen anything in terms of guidance that we would be considering issuing at the moment, but I think it is a very important issue that you have raised, because the safety of staff and, as you say, their morale, and the fact that the NHS should be looking after them as much as looking after the patients, is very important. Perhaps it is something that I could undertake to raise with officials and to look at myself.

Moving on to chlamydia, you have spoken about the pilots that have been going on in the country. One of the issues that we have discussed in looking at those was about the different diagnostic tests that are used, and we are disturbed to hear that the most commonly used test, which is this EIA test, has a sensitivity of only 50-75 per cent, which we have been told means it misses about 30 per cent of the women and nearly half of men. That compares to the more expensive PCR test, which has a sensitivity of at least 95 per cent, but we understand only about ten per cent of clinics are using the most expensive test. What was even more shocking for us as a Committee was to hear that when at least one of the pilots stopped being a pilot, they moved from using the better test back to the old test. Is the Government going to take steps to ensure that the better test is used? Surely it is the most efficient method to make sure the PCR test is standard.

(Ms Blears) The very reason that we have these pilots - and we started the first two in Wirral and Portsmouth and we are now extending to a further eight sites, so there are ten, including those two pilots - is for us to be able to explore different ways of operating, what kind of training we need, what kind of tests we can do, what is the most successful setting, what are the best follow-ups, all of those things that you really only find out from actually doing the work rather than designing a framework sat back in the office. I think it is absolutely vital that we look at all of the evidence about what works, what is the most effective, and clearly we will be looking at cost and value implications as well, because that is a relevant consideration for the NHS in how we spend our money. I can certainly give a commitment that we will look at the evidence from those pilots about the different effectiveness of those tests. Something was brought to my attention that the urine tests are very acceptable to the patient because they are a non-invasive test, and yet I am told that the self-swab, which is invasive but you actually do it yourself, is much more accurate and still very acceptable to the patient. So exploring those different models of tests I think is very important.

Could not some of that be done pretty quickly? To look, for example, at that sub-optimal test, of course, it can get very complicated, but at some reasonably basic level surely it should not take that much time to look at comparing that with the cost of infertility treatment for all those people that you have missed, and the costs of people coming back to clinic if you have missed them. Should some of that not be done quickly? It could be done by professionals, you would have thought, and even within the space of a week they could get together enough data to make absolutely clear that huge difference in results, missing a third of women and nearly half of men, compared to 95 per cent accuracy. That sort of work could be done quickly and then implemented very quickly across the Health Service, which would mean so many people are not being missed.

(Ms Blears) I entirely understand the pressure and the desire to get on with these programmes, because when any of us see the tremendous results from them, we are very impressed indeed. When I see that 75 per cent of people want to take up the option of being screened and of those, 90 per cent come back for treatment, these are stunning figures in terms of the success of the pilots, and I personally think that we should be moving as fast as we can, but I am also conscious of the constraints that we have in the service, and that is about training, about facilities, about laboratory equipment, about storage, the very practical things that I have to take into account before making decisions about how fast we can move with that roll-out. But I think it is a very, very important area, and for me it is very encouraging because, again, the issue is sometimes raised that people do not want to take up treatment, but when you provide it in an acceptable, non-judgmental, easy-to-do way, people are really keen to get their treatment.

I know Sandra wants to push you a bit more on the timescale of this, but the last point for me on this is, we have seen some of the private sector tests for chlamydia that are available on line. People can actually go and get information and talk to GPs online. Have you looked at whether that should fit at all into the strategy, whether NHS Direct should be telling people that that sort of service is also available, or whether the NHS itself should be trying to replicate that for people who might not want to go anywhere near an NHS professional but deal with it all themselves, down the telephone and online?

(Ms Blears) I think the whole attempt through the pilots is to look at different ways of delivering these services, whether it is through community clinics, contraceptive advice, NHS Direct.

So is NHS Direct being used for this sort of online tests being sent out to people?

(Ms Blears) I am not aware that we have a specific project around that, but I do know that NHS Direct is involved with some of our sexual health help lines, and that there is a cross-over there. It is important. Some people go to NHS Direct for advice, and therefore making sure that we are giving the same, proper, accurate and credible information is very important to us. I think we should utilise whatever infrastructure we have. I think increasingly technology is a way that people want to access health services, and if we are talking about modernising things, we have to make sure the NHS responds in a proper, up-to-date way.

Would NHS Direct consider telling people about those sort of services that are available privately, or would there be a policy that you would not tell people about that service because it is not part of the NHS?

(Ms Blears) I have not considered what role NHS Direct could play in this area, but I think increasingly in the public health domain information is power, and giving more people the range of choices they can make is a top priority for me personally, as a Minister, so it is something I would like to look at.

Dr Naysmith

You just said that information is power, and of course that is true, but accurate information is even more important than vague information, and I think it has to be said, Minister, although you have heard some people on this Committee have been shocked and astonished about this, that and the other, it has to be said that some people are more easily shocked and astonished than others. When we were in Sweden talking about this and the PCR test, the people there were shocked to discover that we were not using the most efficient test, and I think there is already enough evidence, if not from our various pilots, certainly from other parts of the world, that it is ludicrous to carry on using the sub-optimal test and we ought to be using the PCR test as quickly as possible.

(Ms Blears) Again, that is something I will look into myself.

Sandra Gidley

We obviously discussed the Wirral and Portsmouth pilots for chlamydia, and there is a prevalence rate of ten per cent among sexually active young women, which seems to me to be very high. I was struck by the fact that all of our medical witnesses called for an immediate national roll-out of the screening programme, and almost for the introduction before the results of the ten pilots were available. I accept what you say about trying to find the best way, but do you have any plans to accelerate the implementation of screening?

(Ms Blears) As I say, we did the two pilots, we now have ten sites, and we are going to be calling for bids in the next year for a further ten sites to be able to extend the process in that way. As I have said, we want to get on with it as fast as we can, but we are constrained by resources and staffing and facilities, as well as learning the lessons from the pilots. That is the reality of the world, but we want to push on with this as fast as we possibly can, because it is a very successful programme.

You say another ten sites. Is that another ten experimental, let's-have-another-look-at-what-we're-doing sites, or are those ten sites where you know what you are doing and it will only be ten more sites around the country that offer chlamydia screening? Which of the two?

(Ms Blears) What we are trying to do is to get an incremental programme here, because the first ten sites have given a commitment that when the central funding moves on, they will fund those programmes from their mainstream PCT funding, and they want to incorporate them as part of their health service. What we envisage is that, as we can roll out more of this, again, using our money as pump-priming money, showing that this is a good project worth investing in, then PCTs will then take them up as mainstream Health Service programmes, but it has to be a phased programme because of the constraints that I have mentioned.

So if we have 200-odd PCTS, we are looking at about 15 years before everybody offers a chlamydia screening service if we carry on at ten sites a year.

(Ms Blears) No. I think that is an unrealistic way of presenting the situation. When you have a new programme, as the screening programme is, you do start with pilots, then your second phase is a kind of consolidation and learning from those lessons, and then, if it is shown to be a good use of investment, particularly following up the points the Chairman has made about investing in prevention rather than treatment, the rest of the Health Service will, I hope, want to put its fairly important resources into that kind of programme. That is generally how we develop things in the Service.

So the second ten sites are the consolidation sites, so there may be more the year after?

(Ms Blears) This is an ongoing programme, and at the moment we are saying that we want to accept bids for ten more sites next year. That is as far as I can go today, but certainly the results that we have had from the pilots are so encouraging that we would hope to be spreading this practice as far as we can across the country.

In a PQ that I asked some time ago, you pretty much said what you have said now, I suppose: "The pace of the roll-out of the programme across the country will depend on the availability of resources." This £47.5 million that we keep hearing about is for two years only. What resources will be available after the two years? How are all these things that are in the strategy, in the action plan, going to be funded in the longer term?

(Ms Blears) I think all Members of the Committee will be aware from the last Spending Review of the massive investment that the Government has made in the NHS. Most PCTs over the next three years are getting a ten per cent yearly increase on their budgets and therefore there will be greater mainstream NHS resources to be able to provide a whole range of services, and that is where the investment will come from in years to come. 1090. I am sorry but I cannot see that that will happen in reality. Most PCTs operate at a deficit; they have huge pressures on their drug budgets; and I cannot see how this is going to become a priority without more impetus and more money from Government, specifically for this service. It will continue to be a Cinderella service. How will you ensure that it is not?

(Ms Blears) I think I have already explained that we have a number of levers in place to make sure that sexual health services become a more important issue at local level through PCTs, through the inequalities framework we have, through the panel and priorities framework we are setting for the NHS, and that there is more investment in the service. I entirely acknowledge that PCTs are under pressure with demands on their budgets from drugs and treatments, but again the challenge for us all is to try and see where we can shift money into prevention and into the front end of our services. If you remember, the whole reason that we got the excellent settlement on the spending review was as a result of the Wanless Report which had the fully engaged scenario where we were putting more money into prevention and the upstream part of the Health Service rather than treatment. That is the basis of our settlement review and we have to remind ourselves of that, and PCTs increasingly, I think, will be looking, whilst having the pressure to do the immediate number-crunching, at imaginative ways to put their money into services such as sexual health which can have an impact on the community.

Mr Burns: Minister, you are very fluently talking the talk but not exactly walking the walk. You came here at the beginning and you agreed with members of this Committee that there is a significant increase in the problem of sexually transmitted diseases in this country. You also said that to many within the Service, and I suspect this was your own view, it was a Cinderella service of the National Health Service. Given that there is a pressing problem with regard to the numbers of people being infected, given that there are pressing problems regionally but particularly with access and that it is a quick time for patients to see people, you have described a pilot scheme. No one would disagree with a pilot scheme at the start to investigate more problems, but the timescale you are suggesting of rolling out a more comprehensive and relevant scheme to seek to deal with what is basically an explosion in sexually transmitted diseases is far too lax to even scratch the surface. You also, and I give you credit because you are a health minister, keep trotting out the mantra about the wonderful settlement you got from Treasury and the increase in spending for PCTs, but I am sure you must yourself have dealings with PCTs as we do as constituency members of Parliament and the situation in the real world is not as rosy as you are suggesting. There are already serious problems in the current financial year beginning to build up with PCTs. My own PCT has significant funding problems and is having to look for cuts in services it is already providing. I cannot see that situation improving dramatically and so I ask you again: given the pressures on PCTs, given the slow programme of pilot schemes and inputting schemes and allowing people to bid, how are we going to deal with this explosion in a genuine health problem on the Government's current, rather lax timescale?

Chairman

Can I just say I am conscious that we have the Education Minister waiting and there are a number of issues still to raise with you, and could I appeal to my colleagues to ask brief questions, and possibly, Minister, could you give brief concise answers?

(Ms Blears) I do not accept that the Government is lax about this issue. The Chlamydia pilots are important. I understand that the next ten programmes will be based on that original model and cover larger areas than the first ten, and we do want to press on with them. PCTs are under pressure but many of them are implementing real improvements that we see from our own constituencies - I certainly see it in mine.

John Austin

I am tempted to ask what position the PCTs would be in if they were at the level that Mr Burns mentioned in his question, but I cannot! Can I clarify one point: when I referred to the £47.5 million earlier I referred to it as being for two years and I think you corrected me and said three, whereas in the evidence we have it does say two, so perhaps that could be clarified to the Clerk in correspondence?

(Ms Blears) Certainly.

Could I come on to the issue of HIV and Aids that was mentioned earlier, and the evidence we had from the Terence Higgins Trust? No doubt you have also seen the report Disturbing Symptoms which was published by the British HIV Association and the National Association of Providers of AIDS Care and Treatment, which was Terence Higgins, and you referred to one of the areas in their findings - namely that one in five PCTs had no appointed lead for sexual health and HIV - and you indicated that you were taking steps to persuade PCTs to appoint lead members, but that report also showed that two thirds had not completed an up-to-date needs assessment and more than one in four had not included sexual health and HIV in their service and financial framework. You referred earlier to the need to monitor what was happening and, indeed, that sexual health services are to be monitored through the service and financial framework, but we understand that sexual health is not one of the must-dos as far as PCTs are concerned. Is that not one of the steps you could take to ensure that monitoring did take place, and what other steps could you take to ensure that these gaps at local level are filled?

(Ms Blears) This is a very important issue. The latest figures I gave you on PCT leads were that we have them in 286 and there are only 18 outstanding, so we have made significant progress since the report you had in making sure they are in place. In terms of the SAF, I understand that from next year we will be moving from service and financial frameworks into local delivery plans so there will not be the SAF mechanism. We have it for this year and we expect to get the returns in April, I think.

So this will then be a must-do? A compulsory?

(Ms Blears) No. Sexual health is not included in the local delivery plans and that is why I made reference to the inequalities framework, because that is in those local delivery plans and sexual health clearly relates to inequalities right across the piste in terms of services available and the kind of people who disproportionately suffer from sexually transmitted infections, and therefore that is the route. But where I think the strongest area is in terms of monitoring not just investment but, more importantly for me, the outcome as to what is happening is through the Aids Control Act returns. In the past I do not think the data collected through that would enable us to have a real handle on what is happening in those communities and therefore we propose, and I think I am going to get a submission on this fairly shortly, to look at how we can change the data required through those returns to give us a more accurate view of how money is being invested, both in prevention and in treatment, in this important area. I would say to the Committee, however, that a decision was taken to remove ring-fencing because that is a policy direction in which we want to go generally. Everybody will know that the demands of the service, not just in the National Health Service but in local government as well to try and minimise ring-fencing so that we maximise local decision-making, is an important policy direction for the Government as a whole, and it is very difficult for the Service to plan when lots of different pots of money are completely tightly controlled. If we are genuinely about trusting local communities to decide what is in the interests of their areas, then I think as central Government we have to be prepared, within the national framework of standards and regulation inspection, to let those decisions go out to local communities. But I am concerned about this issue and we have just done a sample survey, and I am happy to share that with members. It is only a small survey but it is a cross-section, and it looks at prevention and treatment and the figures appear to be holding up extremely well in those terms.

You refer to local decision-making and I think this Committee in this inquiry, as in the mental health inquiry, shared the view you expressed earlier on the importance of the voluntary sector and that the National Health Service cannot do it alone, and I think we have evidence that particularly in areas of black minority and communities the role of the voluntary sector is quite crucial. What assurances can you give us that the level of funding and support for voluntary groups will continue since it is going to be largely left to local decision-making?

(Ms Blears) Clearly the voluntary sector at local level will be important but we also think the voluntary sector nationally is very important here in terms of the funding we allocate to the Terence Higgins Trust, the National Aids Trust, and particularly the work around African communities increasingly. We fund those organisations, a million pounds has gone to Terence Higgins, and that funding will still be continued at national level to make sure the very important work that those national voluntary organisations are doing is able to continue. I am particularly keen that we support the development of work with communities from sub Saharan Africa because if we look at the epidemiology in terms of HIV we are beginning to see a significant rise in that part of the community, and it is an area where we have not necessarily had some well-developed information materials. The voluntary sector is much better placed than we are to do that work out in the communities. Also, I understand we will be able to use the Aids Control Act to monitor local investment in the voluntary sector so I can give the honourable gentleman that extra reassurance.

Mr Burns: Very quickly on your last point, what proportion of patients being seen are genuine asylum seekers, and what proportion are not?

Chairman: I think that is beyond the Minister's ability.

Mr Burns: But she was talking about Somalia --

Chairman

Minister, if you want to answer it, fine.

(Ms Blears) I do not have that information, Mr Chairman.

John Austin

In June of last year we asked your officials how the primary care trusts would be reimbursed for treating HIV patients resident in other areas, and we were told there was no definitive answer at that time. Can you clarify the situation now that HIV matters are firmly in the mainstream?

(Ms Blears) Yes. It is obviously for PCTs themselves to sort out a mechanism for how they are going to reimburse each other for treatments provided. Obviously, if you have a really good centre - and somebody mentioned Newcastle which I have not visited but apparently services are very good in Newcastle - it attracts people from all over rural areas to go for treatment, although clearly every PCT is responsible for the cost to its residents so there needs to be a local mechanism agreed as to how those costs can be apportioned. We have just issued the commissioning toolkit. I am sure honourable members are very familiar with toolkits that the National Health Service issues but that is a series of recommendations, a good practice guidance, how to do it, and in there we cover areas such as PCT consortiums, getting together to commission, and also how we can work out the prices where we can get the recharging mechanisms in place, so there is guidance now for those PCTs about how to agree the mechanism in their own local community. It is not a matter for the centre to dictate how they should do that but we will be giving them support to enable them to get robust mechanisms in place.

There has been some suggestion that individual PCTs would be invoiced when their residents use HIV services elsewhere, and it has been suggested to us that that system would be unworkable. What is your view?

(Ms Blears) That is not a model that I have seen. I am certainly not an expert in this area but in the toolkit I am told there are some examples where people have had a lot of experience of doing this. For example, in north and south London where services have been in place for a long time they have a lot of expertise about getting a basic price and then being able to do it without individual invoices but actually on a more consistent basis, and I think we need to spread that practice across the country. Again, however, I do not think it is for us at the centre to dictate how PCTs should do that. They need to do it in the way that is most cost effective with not a lot of bureaucracy and not a lot of form-filling but which gets an accurate reimbursement, because PCTs are funded for their residents and rightly should be responsible for the cost of treating them. If the PCTs have a consortium, which we are urging them to do for commissioning because it is specialist commissioning, then they could have a lead person in that consortium responsible for sorting out the budgets and the recharging mechanisms. We do not expect every PCT to be doing this - it would be a waste of time. They should using the expertise they have in a group of PCTs to take on these roles.

So are you confident there will be transparency on how the HIV budgets are spent, that the allocation of funds to providers will be adequate, and there will be management of financial risk?

(Ms Blears) Yes. In this, as in every other area of the National Health Service, it is incumbent upon us to make sure that the investment we are asking the taxpayers to fund at the end of the day is properly spent and managed and that we can see what kind of results we get for the investment, and I think in HIV services, as in any other area of the Health Service, we want to see that improved investment does result in better outcome for the patients, and that is something we would all subscribe to and be determined to see happen

Mr Taylor

Minister, are there any plans to ration anti HIV drugs or regulate control the entry of new drugs?

(Ms Blears) There are no plans to ration access to clinical treatment.

That was a snappy question and a snappy answer. Again very quickly, there have been calls for compulsory testing of asylum seekers for HIV because we know the large proportion of new heterosexuals are bringing it in from abroad. What is your view on compulsory testing, or even voluntary testing for asylum seekers?

(Ms Blears) Certainly at the moment our policy is to have voluntary testing. Anybody can get a test at a GU clinic in a confidential and sympathetic environment, but there is a review going on between the Department of Health, Home Office, Foreign and Commonwealth Office and the Cabinet Office to look at the whole issue of imported infection and immigration because it is not just HIV but also other serious communicable diseases involved, and therefore we are right at the beginning of a scoping study to look at the facts and see what the issues are. Clearly in a changing international and global situation it is important that we look at the implications for infectious diseases as a whole.

Considering some of our long-term residents cannot access these clinics, if it is going to be voluntary for newly arrived people to find a clinic and have a test, it is not going to be very effective, is it?

(Ms Blears) There is a pilot at the moment in east Kent where newly-arrived people have a medical assessment and are being referred to TB screening and that may be something we want to look at, but obviously that is a pilot and we will be learning the lessons from what is happening in east Kent.

We have been told that the Aids Control Act figures are not felt to be reliable by providers or commissioners. In fact, the Sofit data is used by the PHLS and still has its problems. Why such emphasis on figures gathered from an unreliable source?

(Ms Blears) I am not aware it is an unreliable source. As I say, we do need to look at the way the Aids Control Act returns have functioned, and I will be getting some recommendations from officials to see if we can make that information more relevant and appropriate, but I am not aware of the fact that they are said to be unreliable.

Chairman

So you contest that?

(Ms Blears) I have not had information that they are unreliable.

Jim Dowd

Just following that up, the term "newly-arrived" is used in this context. Could I ask you for your view on UK nationals who may have returned from areas of high risk? Will the study look at those as well?

(Ms Blears) At the moment the Cabinet Office are right at the beginning - they have only had one meeting - and they are looking at scoping the issues of imported infection and immigration. I am not aware whether they are looking at that specific issue but that is something I would certainly feed back to the group. I think it is important because the term "imported infection" means that any of us could be importing infection in those terms, so I will feed that back into the review that is currently being established.

Can I move on? You have been into detail about the apparent friction on the role of PCTs in sexual health and also you mentioned reducing ring-fencing. It is very difficult in a National Health Service to guarantee national standards and yet have a degree of devolution where local budgets can be spent effecting that, so the National Service Framework obviously exists to address that in certain areas. However, sexual health does not really feature in that and is unlikely to, and given that we have had evidence that one in four PCTs have not included sexual health within their service and financial frameworks, are you sure that this system is robust enough to give this the priority it deserves?

(Ms Blears) In terms of a strategy, what we have tried to do in sending it out as levels 1, 2 and 3 is to provide a framework for PCTs to look at what they have in their community; does it fit; have we got the level 1 services; level 2; level 3; are they in the appropriate place? So in those terms it is a framework for what a good service should look like. That is backed up by the commissioning toolkit which is very lengthy but I make no apologies for that because it goes into great detail about what a good service can look like, how to commission it and design it, make sure it works in practice. So all of that information is out there now. In terms of making it happen, as I say, I think increasingly we are seeing PCTs take up the agenda and those PCTs will be performance-managed by the strategic health authorities on their delivery of services, and it is very clear that PCTs are required to provide a range of sexual health services in their community varying from contraception services through GPs and community clinics to sexually transmitted infections, then to HIV specialist commissioning. So there is a number of different roles that they have to undertake and they will be performance-managed by the strategic health authorities on how well they are delivering across the range of their responsibilities. The very fact we have a strategy - and I know it is not an NSF but we did not have anything before, and it is this Government that has decided this is an important area of work and therefore we have our national strategy - and our Ten Year Plan, our communications programme, and our significant investment sends a very clear message to the National Health Service that this is an important area of work - perhaps more so than it has been for decades in this country.

Moving on to sexual health strategy and sexual dysfunction, it is mentioned fleetingly in the strategy but we have received evidence saying that in the US, for example, there is research data to say 50 per cent of all people will suffer from sexual dysfunction of one kind or another. Why is it not given more prominence in the strategy?

(Ms Blears) It is in the strategy and in the action plan and I know you have evidence from officials that we are about to develop the sexual health standards to back up the action plan, and there will be more work done on it. Initially it is fair to say it was not a big issue in the strategy because the pressures were about the waiting times, the pressures on services, the increasing number of sexually-transmitted infections - those were the big drivers for why we needed the strategy - and therefore though it is in there and will be developed I think it is fair to say that it was not at the heart of the strategy in the early days. I think increasingly, however, the issue of sexual dysfunction is becoming more widely acknowledged and recognised but is not again just a medical issue; it is about a whole range of primary care services, counselling, psychological support, and community support, and therefore perhaps it needs to be assessed in a more imaginative way than simply looking at it in terms of medical services.

Sandra Gidley

Psychosexual counselling is very low in priority but what is available which helps many people are anti impotence preparations which are restricted in access. Government a couple of years ago did a consultation and 98 per cent of the responses said that the access to the drugs should be widened and Lord Hunt said, "No, we cannot do it, because we have not got the money", in which case what was the point in doing the consultation, but there is increasing evidence to show that men taking anti impotence preparations have thrown away the anti depressants, for example. Has the Government looked at that aspect to see if, in effect, in the same way as screening, there is a long term benefit in making these products more widely available?

(Ms Blears) This was quite a difficult area of policy-making when decisions were originally adopted because clearly there are pressures from a number of different areas to make those decisions, and I think the decisions reached were the right ones - we have certain circumstances in which the products are available but we take into account the priorities and the pressures that are on the National Health Service and have made the decision accordingly. I am not aware of any research myself about the long term savings that might accrue as a result of investment in this area, but I am satisfied that the decision in relation to the criteria is the correct one

Andy Burnham

Could I move you up, Minister, to teenage pregnancy and unintended pregnancy? Looking at the earlier figures the trend seems to be going the right way finally. Could you comment on that?

(Ms Blears) Yes. We are I supposed quietly delighted that the teenage pregnancy strategy is having a significant effect, and also that the numbers appear to be coming down in the areas where we have done the greatest work, and it is always particularly heartening that it is evidence-based that what we are doing is making a difference. We do have the largest teenage pregnancy rate in the whole of western Europe so it is a key priority for us and it is working, and I think it is that combination of issues in the strategy making it effective - not just access to services but also the information campaign and the support for young parents to get back into training and work together with the sex and relationship education, so it is a multi-faceted approach which mirrors the sexual health strategy which again draws it in a range of responses really.

The health of the nation target to reduce teenage pregnancies under 16 by 50 per cent failed - the document launched in 1993. What is different about this? Is it the rounded nature of the approach to teenage pregnancy that makes it different?

(Ms Blears) I think very definitely. I have a sure start plus programme in my own constituency and I have talked to some of the people involved particularly in terms of getting young mums back into education and training and giving them a sense of future, that it is worthwhile looking at qualifications and all that kind of issue, and that is hugely important, as well as access to good quality contraceptive advice.

Is that side of it more important? The kind of life chances, aspirational education?

(Ms Blears) I think the evidence is that where you get high rates of teenage pregnancy it is inextricably linked with people who have a sense that life does not offer them very much, and with social class, deprivation, poverty and lack of ambition, but access to good services, proper information, sexual relationship education and life chances is the way you do this in the round, I think.

I notice in the national strategy there is a general target to reduce unintended pregnancy not just teenage pregnancy, and the majority of unplanned pregnancies and abortions occur in women aged 20 to 30. Is there a danger that there is too much emphasis on teenage pregnancy at the expense of focusing on women slightly older? Secondly, I do not think there is any specific target on women in their 20s and 30s. How are you making the progress you want to in that older age group when there is no clear target?

(Ms Blears) I think we want to do both. We want to try and reduce unintended pregnancies across the board but I make no apology for focusing on teenage parents and young people because the evidence is overwhelming that multi pregnancies in the very early years affect people's life chances right the way through. I think it is important, however, that older women as well in their 20s, 30s and 40s have access to really good contraceptive facilities. There is a need to make sure that people have the whole range of contraception - not just simply the contraceptive pill - and good advice about what is suitable for them. So I think contraception needs to be highlighted too.

Moving on to that point specifically, we have taken evidence that contraception services are patchy and have disappeared in some parts of the country, and that access to contraception varies quite markedly. The young people who came before us last week talked very much on this particular point about the difficulties that they found with accessing condoms and talked about having them in the toilet in the pub but that they were very low quality and were not safe to use. Are you looking at that area particularly, and how you improve access to contraception?

(Ms Blears) Yes. Inextricably linked with the GP contract, which we are currently negotiating at the moment, for most people their first port of call is GPs but community clinics are very important particularly for young people who do not want to go to their GP. I had the pleasure of meeting some of the young people from Yorkshire who had done a survey of their local contraception clinics and one young women, only 16, a fantastic girl, had gone into this clinic, stood there for ten minutes, nobody said "Hallo" to her, and I think on the table they had Gardener's World and on the television they had Countdown, and she said it was the most inappropriate setting for 16 and 17 year olds and that if they had put some teenage magazines out and had Radio 1 on then it would have been a lot more welcoming. Simple practical suggestions like that make a world of difference in making people feel welcomed at contraceptive clinics.

Presumably these are the value added, one stop shops, the three pilots to take it away from GP services?

(Ms Blears) We do not want to take it away; we think there should be a range of services. In some places GPs would be perfectly appropriate and could be providing extremely good services but in other places people want to have the choice, so we are saying to PCTs that their responsibility is to put in place a choice and a range of services for their local community that meets their needs.

And is the GP contract not just quantifying how much contraception, because then there is a target that says that it is very much quantitative rather than qualitative backing up GP training and what advice is given with the contraception. Will the contract get on to that particular issue?

(Ms Blears) I do not personally know the details of that module in the contract. Clearly it is still subject to negotiation. I think GP services do vary and, again, I think some GPs have a real interest in this area and want to provide a whole range of services; some might decide to provide a fairly limited service in their community.

Lastly, the Sex Lottery advertising campaign. The very same young girl you were just referring to talked to us about it and said she found it effective and it made you read it and it was quite arresting really, but that the focus is on STIs and not on unintended pregnancies. Is there any intention to carry on the same theme but also to push the idea of teenage pregnancies and unintended pregnancies?

(Ms Blears) In a way it is almost the reverse. We have had a really good campaign on teenage pregnancy. 70 per cent of the intended audience are aware of the messages and we have built the adult sexual health campaign aimed at 18-30 year olds on the teenage pregnancy information campaign. The Sex Lottery campaign is controversial but is hard-hitting, it has humour, it is credible with realistic information, it is aimed at that group of young people, not us, and really does seem to be having an effect. I am looking forward to the evaluation of that campaign later this year and looking at the awareness and the effect on behaviour. As I said right at the outset, this is about immediate services but also that long term behaviour change, and I think the sexual health information campaign is going to be really instrumental in getting that long term change we need to get into the system.

Dr Naysmith

Another area recognised in the teenage strategy, although as Mr Burnham has pointed out it has a wider relevance than teenage, is the unacceptable variation in access to abortion services throughout the country, so the new maximum three week target that is suggested is very welcome to lots of people. However, the Family Planning Association said to us that this could make things worse in a funny sort of way because there are pressures at the moment on the Service with a shortage of consultants, patchy access to GP referral for contraception, and inadequate provision of information in many areas, and in some communities in areas where information is available to some and not others. What is the Government doing to address these problems which are fairly widely recognised, even though the three week target is widely welcomed?

(Ms Blears) We think this is a very important area for us to make sure there is equity of access across the country to early, safe abortion provided the women obviously meet the legal requirements, and we will be monitoring this very carefully. We put a million pounds this year into the areas where abortions were taking place much later than we would have wanted. There were 51 PCTs where we targeted that money who had the longest referral times, and it is right to say it is patchy across the country. Some places are doing extremely well and in other places it is far too late. I am particularly concerned about young people who tend to present later in any event and therefore getting them swift access is very important. The target is for three weeks from the first referring doctor and we intend to monitor that waiting time extremely closely to make sure that women can have proper access. It is a very important issue indeed. It is about putting more money in but it is also about making those services more available locally as well. 75 per cent of abortions in this country are funded through the National Health Service, 45 per cent of them are undertaken in the independent sector, and we want to be looking at the referral patterns to see where the delay comes in to the Service and can we re-design it to be quicker and faster.

It is interesting that you say that teenage pregnancies tend to be referred later. What can you do about that? That clearly is information, one suspects. It may be information on different aspects but it is certainly information, I think?

(Ms Blears) Very much so, information and confidence to be able to get into the system, and I think making sure that information is available on a wider range of settings for young people is very important, not just simply through the GP but also through their advisers, their contacts with youth workers in any of the settings where they would feel comfortable, and having confidence and trust and making sure they have quick access and proper support.

Chairman: At this stage could I bring in the Education Minister in and express our thanks to you so far. Please remain with us for the rest of the session because there will be issues where we may want to question you. Can I welcome you, Mr Twigg, and say how grateful we are and apologise for keeping you waiting so long. Your ministerial colleague gives extremely long and thorough answers.

Jim Dowd: Not as long as some of the questions!

Chairman

Could I ask you to introduce yourself to the Committee and say a little bit about where we are with the sex education elements of your responsibility? One of my colleagues, Mr Burnham, made the point that there has been an announcement over the last few days which relates to this, so could you mention where you are on this?

(Mr Twigg) Thank you very much indeed. Can I say, first of all, that I am very pleased to have the opportunity to join you here today and I think our Department, along with the Department of Health, very warmly welcomes the inquiry you are undertaking and the important contribution it can make to the development of policy in this area. I am the junior schools Minister and amongst my responsibilities are two curriculum areas that I think are relevant here today which is PSHE and citizenship. I think the key two milestones of the recent past were the publication by the previous Department for Education and Employment in the 2000 of this document, Sex and Relationship Education Guidance, and the more recent publication last year of Ofsted's report on Sex and Relationships. I think what the OFSTED report demonstrates is that a great deal of progress has been made that the new guidance we issued in 2000 has had an impact in most but not all schools, but that a great deal of further work needs to be done particularly in the area of training and professional development for teachers, and I think if there is one key lesson that we have taken as a Department from the Ofsted report it is the need for us to do more working with colleagues in the qualifications and curriculum authority in this area. We have a programme that we are launching this year of new continued professional development training for teachers, both in primary, secondary and special schools, starting with 500 teachers in April and then a further 250 in September which we see as an important first step to get a more consistent practice across schools around the country. On Andy Burnham's issue about the announcement this week, we had it on Tuesday of how we are taking forward 14-19 education, and as part of that we reaffirmed that sex and relationship education remains part of the core curriculum between 14 and 16.

John Austin

Several of our witnesses have said that the reason that services fail to meet the needs of young people is that by and large they are designed by older people who have not much clue about the needs of young people. We saw last week in our evidence young people themselves who were quite clearly talking about what they felt they needed and wanted, and if you have not seen the evidence I suggest you get the video! I think I speak for many of my colleagues in saying how much we deplore the way some journalists portrayed the very serious evidence that those young people gave to us. What mechanisms are there in place in your department to ensure that young people feed into the policies and the programmes? Have young people had any input into the design of the latest Sex Lottery information campaigns?

(Ms Blears) Starting with the Sex Lottery campaign, absolutely. We have tested this almost to destruction I think on the target audience we have. This campaign is aimed at adults 18-30. Within that group there are two distinct groups, the 18 to early 20s and the older people, and they have been involved in the whole design from day 1. That is partly why it is controversial and partly why it is effective, and they said time and time again that they want information that is relevant, credible and in places where they go. There has been talk about it being in pubs and clubs and washrooms, but that is exactly where young people are likely to meet their sexual partners - well, maybe not in washrooms! - so they have said that that is where they want the information that enables them to make those choices, so this shows to me that if you do consult with young people in developing your policy you will get a much more effective product at the end of the day which means we spend our money wisely and well. Right across the Department, in everything we do, involving young people in social care as well as in Health Service is absolutely fundamental and we are getting better at it. I would not say we are perfect but we are getting better.

(Mr Twigg) I have not seen the video of the evidence in Manchester but I have read an account of it and it certainly fits with the discussions I have had visiting schools or with other groups of young people, and very much reinforcing what Hazel Blears said clearly we have to involve young people centrally in the development of these materials, so as we take forward the advice on personal social and health education to schools we are involving young people at every stage. We have a very close working relationship as a department with the National Children's Bureau and we use them for a lot of the different materials that we develop in the whole area of citizenship and PHSE, and I know that two of their officials have been before you.

Andy Burnham

The four young people before us last week were all my constituents and one of them went to the same school as I did and I asked them to give marks out of ten on the quality of the sex education they received at school. I have to say they were all pretty negative and it does not seem to have improved a great deal since I can remember in the 80s. Having said that, though, I think there is a growing body of evidence about what constitutes an effective - and you refer to your own departmental work - sex education and relationships programme. Given the mismatch between what seems to be happening on the ground in parts of the country and what you know, what is the DfES doing to bring the quality of what is being done in schools up to an effective programme?

(Mr Twigg) Firstly, our guidance is still relatively recent. What the Ofsted report shows is that whilst a majority of schools have looked again at their own policies in the light of our guidance, quite a significant minority of them have not, and firstly we have to encourage more schools to do that. Clearly the specifics of these policies are developed at the school level and it is right that that should happen, but we do want to see all of the schools in this country looking again to ensure that they are taking into account all the different elements.

It is right that that should happen because one of the messages the young people are giving us is that it is so important this information to them that it cannot be left to the whim or the particular character of an individual within the school, and we need to be sure that all young people are getting an absolute basic level of sex education. There was a suggestion that it is not good enough to let it vary from one school to another possibly for religious reasons or whatever, and there needed to be a basic minimum that everyone was getting.

(Mr Twigg) Yes. There is a basic minimum in terms of the compulsory parts of sex and relationships education generally delivered through the science curriculum, but we have a particular project at the moment to gather the very best practice on sex and relationships education teaching so we can spread that practice, because I do not get a sense mostly that there is any resistance to this in schools. It is often that it is not given sufficient priority, but schools do want to do their best.

Is there a moral question?

(Mr Twigg) Not generally.

It might be the other academics that might be taking a higher priority?

(Mr Twigg) Exactly and it may be, coming back to the changes announced earlier this week, that with some loosening of the secondary school curriculum there may be more scope within the school timetable that is to be treated more seriously than in some schools at the moment.

We have received evidence about the age at which it should start but there was consensus amongst our young people that for them it started too late. What do you think is the average age at which sex education should start in schools at the moment? What is the optimum, do you think?

(Mr Twigg) Relationships education and the scientific aspect of sex education starts in primary schools but clearly the issues that relate to sexual relationships comes up in secondary schools. I think I have an open mind about that and would want to study the evidence. If young people are clearly saying that through their evidence to you or the National Children's Bureau, what I prefer to do is take that away and have a look at that and see whether that has any implications for our guidance.

Chairman

Can I just come in on this important point? When you say that this will take place in secondary schools, what age are we talking about here? At what age within secondary education would it be?

(Mr Twigg) Mostly 14. There are elements that are between 11 and 14.

Are you aware of the average age of first intercourse now?

(Mr Twigg) I think the average is probably 13.

No, the average age of first intercourse

(Ms Blears) Sixteen.

(Mr Twigg) I thought it was a trick question!

I hope you are wrong on the answer you gave! The point I would make is that, if the average age is 16, then obviously there are some starting well before 14.

(Ms Blears) About a third are having first sex under 16.

It is a fact that there are many girls who are menstruating in primary education, so is this not an issue that we need to be looking at very seriously?

(Mr Twigg) Yes. This has been looked at in some detail and it is set out in our guidance and also the Ofsted report what we are expecting at each stage. What I think I prefer to do is take that away today and look at whether we need to be introducing some of the elements that come in at 14 at an earlier stage in secondary or even primary.

Andy Burnham

Picking up on that, young people also talk about pressure or expectation that they may become increasingly sexually active at a younger age. Do you think there is a danger that, if it starts too early, that may reinforce that pressure on young people to be sexually active? It is a difficult balance.

(Mr Twigg) Yes, but I think the evidence is pretty clear that sex and relationships education does not have that and, if sex and relationships education is partly about making clear that young people have choices and that they can say no, it could have a positive impact in terms of issues like teenage pregnancy and sexually transmitted infections.

Finally, given the variation within schools and how some schools go about implementing the guidance from the Department and others, we have heard a number of calls for the PSHE sex education element to be made a statutory part of the national curriculum, because it is so important to young people and their lives and their life chances. What is the latest thinking in the DfES about that?

(Mr Twigg) We are very sceptical about doing that. It is put to us on a regular basis by the National Children's Bureau who feel strongly that this should be the case. The whole direction of policy in terms of the national curriculum as signalled this week in the announcements on Tuesday is away from compulsory elements in secondary, so we have taken modern and foreign languages and design and technology out of the compulsory part of the curriculum. Teachers have also expressed concern that, were we to make this a compulsory part of the curriculum, it could impact on their ability to be flexible with the way in which PHSE is taught.

If it becomes compulsory, I would guess that you would then get the back-up of better training in teacher training colleges because people know it is something they have to do in secondary schools, so there might be pros attached to it?

(Mr Twigg) That is a fair point. I think looking at the Ofsted report there is not an issue about whether schools are delivering PSHE but about the quality and the priority it is being given.

Young people talked about the variations of how teachers handled it and whether they can approach one teacher or another.

(Mr Twigg) Exactly, and I think that has a lot to do with the levels of professional development and training being provided and, as you alluded to, teacher training, both initially and then through teaching, and that is what we are focusing on. What we hope to achieve as a department is the improvement without having to add an additional element into the compulsory school curriculum, but we will keep a watching brief on that.

Dr Naysmith

On the area of teacher training, it seems to be clear from the evidence we have had that a lot of teachers do not feel confident, and the children recognise that the teachers are not confident in taking some of these lessons, and it is important to get that sorted. You imply that you are looking at it but if we are talking about this area at all it is really something that has to have high priority, is it not?

(Mr Twigg) Absolutely, and getting it right is important. We had a pilot project on this with 37 volunteer teachers in the autumn which was very successful and out of that we now have this new programme of continued professional development that I referred to in my opening which is going to have 750 teachers this year.

But that is a drop in the ocean.

(Mr Twigg) I recognise that but it is a first step and an important one. Also, what the Ofsted report highlighted was some excellent practice already going on in many schools, and I think part of what we want to do is share that excellent practice across schools, and I referred to the particular project we have which is looking at that at the moment.

Also, in this area, what came up in our inquiry both last week with the young but also in Sweden and in Amsterdam when we were looking at various matters, is that it is not necessarily teachers who do this sort of education best, and Hazel Blears might like to comment because people talk about community nurses and youth workers being able to do this much better, maybe even coming into schools or special clinics associated with schools.

(Mr Twigg) I think that is very important and a major change we have seen in education in recent years is the far greater number of other professionals and adults working in various roles within schools, and I have seen very good examples of learning mentors sometimes in the Excellence in Cities programme working closely with young people whom teachers find it difficult to work with, and part of that work is to do with sex and relationships education. We also have our pilot extended schools programme, with 25 schools around the country looking at the other facilities that can be provided on a school site. Twenty of those are having health projects as part of that which Hazel Blears can say more about, and that is an important component of any successful strategy on sexual health.

(Ms Blears) We have increasingly got a number of health facilities attached to schools and it is a range of workers who are in there: sometimes it is just one school nurse on his or her own and sometimes there is back-up, with maybe a GP or a range of primary care professionals as well. It is done entirely with the agreement of the governors and the parents in that community, and the early evidence of those facilities is that they are extremely well valid and used by the pupils, and that there is a real opening up of some of these difficult issues. Also what is interesting, as you mentioned your visit to the Netherlands, is that I understand that conversations there between parents are at a much greater level on these issues than in this country, and people for cultural reasons find it easier to talk to their mums and dads, and this is an important area of sex and relationship education - perhaps particularly the relationship side of the education. In my community we have a project at the moment working with young people where sex has almost become a kind of brutal commodity, and trying to get the young people to have respect for themselves and their bodies and their relationships is a key issue in trying to delay the age of first sexual experience which is a key strand of our teenage pregnancy strategy - to give people that sense of self respect to make sure we can support them in the choices they make.

Chairman

May I just say that the British have a problem with sex.

(Mr Twigg) Yes. There is a particular issue that is highlighted in the Ofsted report about boys, and we are doing some work, again with the National Children's Bureau, about the advice available particularly for assisting boys and particularly the relationship between fathers and their sons.

Chairman: We would like to come on to that later on.

John Austin

On the question of the relationships education, surely that is something which started at a very early age and maybe sex comes into it but on the national curriculum, as long as personal health and social education remains outside the statutory part of the national curriculum, does that not mean that sexual relationship education is subject to the whim, the content, the timing of particular government bodies and schools? Do you have a closed mind on this or are you willing to reconsider the question of whether it should be part of the national curriculum?

(Mr Twigg) I certainly do not have a closed mind on it. I recognise we need to keep a watching brief on this. I have to say the direction of education policy, particularly at secondary level, is away from prescribing more elements of the curriculum, so although we have quite recently introduced citizenship as a core part of the curriculum which has some relevance for the work on the relationship side of sex and relationships education and I have seen some good practice where citizenship is being used in that way, we are sceptical about adding further elements on to it, but I am very prepared to look at the evidence and, if there is evidence that our failure to do that results in schools not delivering, we would have to look at it again but I do not see that in the foreseeable future.

Andy Burnham

When we were in Sweden, we heard that young people are in education up until 18 - I think 95 per cent or more. Is that not a crucial difference between Sweden and this country, do you think, in terms of young people? In my constituency less than 49 per cent stay on post 16. What evidence do you have that the increasing staying-on rate impacts on these issues in particular?

(Mr Twigg) It must do. We have seen very considerable progress in this country probably over a period of ten years towards far more of our young people staying on after 16, but it is still the case that if you look at a table of the advanced industrialised countries, we are almost at the bottom with a figure of around 72 per cent nationally, which obviously varies greatly between different communities, and Sweden is right at the top with I think something like 98 per cent of their young people staying on and that must have implications for issues we are talking about here today.

(Ms Blears) The connection of that with teenage pregnancy is absolutely there. It brings us back to that issue that we talked about: if people think they have life chances and that getting an education is worthwhile then they will not get pregnant so early.

And if there is an expectation that you will be staying on in education till 18 it changes your whole life, and raising the staying-on rate may be a way of tackling this.

Julia Drown

One of the clear messages we heard from young people was that yes, it was partly up to the personality of the teacher whether sex education was effective or not but that even with the good teachers they preferred a one-to-one sort of session if they were really going to ask questions, and clearly there are some issues of practicality there, but what they all agreed was that they would be prefer to be taught by their peers. Now, in your guidance do you talk about that at all because it did seem to be one of the most effective ways of getting the message across, and also empowering the peers you are training to do the teaching. Also, on teenage pregnancy, what was clear from the teenage mums who spoke to us was that they found the electronic dolls they had experience of, after they had become pregnant, were a really practical way of learning about some of the realities of being mums, a practical way that is not reflected by sitting up and listening to a lecture. Is there any prospect or have you any plans for those electronic dolls to be made more widely available, particularly in the areas of high teenage pregnancy rates?

(Mr Twigg) On the peer education point, that is absolutely central and it is part of our guidance and there is some really good practice going on on this in schools already. On the electronic dolls I know there are different views and our colleagues at the National Children's Bureau are somewhat sceptical about this one. I visited a project in Rawmarsh in South Yorkshire where they certainly swear by these as a method that can actually reduce the levels of teenage pregnancy there. I would say that personally it seems quite a persuasive argument but I am not sure that the evidence is conclusive as to how effective it is.

(Ms Blears) I think that is right. I have been up to a project in the North East and seen the young mums with the dolls and apparently they cry incessantly, you cannot switch them off, and they found that very persuasive. The evidence is not totally conclusive on that. In terms of peer educators, I met a whole range of peer educators on the teenage pregnancy programme, some from Wakefield, some from Sheffield and also, interestingly, some from New York who had come over to share their experience with us and they were some of the most effective educators that you could hope to meet because they had been there, they had the experience, and they talked to the young people in terms that they understood. I think you make a very, very important point. We have just published a peer education good practice guide to try and draw on this information and I really do think it is what young people want to hear in a way that is effective.

Sandra Gidley

We heard from teachers, educationalists and young people themselves last week that issues to do with homosexuality are not addressed adequately by schools, if they are addressed at all. Many of the witnesses thought that this was down to Section 28, but given that young homosexual men bear a disproportionate burden of the incidents of sexually transmitted diseases, are there plans to address this?

(Mr Twigg) I think there is a number of different aspects that we need to deal with here. One is, of course, issues around bullying and one of the concerns that I have got is that although we have been saying as a department that schools should adopt policies specifically addressed at different forms of bullying, including racist bullying but also including homophobic bullying, the numbers that have actually done so are very, very small. This is an area that we certainly need schools to address as a much greater degree of priority. That is on the particular issue of bullying. On Section 28, clearly technically Section 28 does not any longer apply to schools but in practice Section 28 does act as an inhibitor, I think there is absolutely no doubt about that. Not only is it, I think, symbolically a badge of prejudice it is actually in practice leading some teachers to feel that they have to hold back in terms of dealing with issues around homophobia and issues around sex education and, therefore, the sooner that we see the successful repeal of Section 28 the better that it will be. I think that if we can create an atmosphere in schools where prejudice is seen as unacceptable then it is going to be easier not only to tackle homophobia but to teach honestly in terms of gay sex and lesbian sex within the sex education curriculum. I do think that the citizenship strand is very important here, that a key part of citizenship is not simply the political literacy but is actually about community, about values, about tolerance and tackling prejudice. I think that will make a difference to do that as well. I think one thing I need to do is to look at whether specifically on the sex education as distinct from relationships education and citizenship perhaps there is more that we need to do in terms of the curriculum materials that are made available to schools.

Repealing Section 28 is something that I would generally support but that only goes so far.

(Mr Twigg) Yes.

You said earlier that you do not want to make anything compulsory.

(Mr Twigg) Yes.

I can see that a lot of people are going to feel very uncomfortable teaching and dealing with this material. How do we get around that? I can see that lots of schools will just duck out of this issue. Have you any plans to tackle that? I agree with all you have said so far but I just wonder how you will do it.

(Mr Twigg) The interesting thing is the history of this document, of course, which was when the attempted repeal of Section 28 was happening in the previous Parliament, in tandem with that this guidance was developed. The idea was to have this guidance, which includes some of the things we have been talking about, in tandem with the repeal of Section 28 but we ended up with just the guidance and without the repeal. Certainly I was not seeking to suggest that simply repealing Section 28 on its own would be sufficient. I think there is a lot of good that is in here and in the content of the citizenship curriculum and what I think we have to do from the DfES point of view is to ensure that that is being given proper treatment and proper priority within teacher education and in particular within initial teacher training. Having seen some of the young people who are training to be citizenship teachers, for example, the issues around various forms of prejudice and discrimination are part of that initial teacher training and I think that we will start to see an improvement coming as a consequence of those people coming into the classroom.

Chairman

One of the points that we have picked up in evidence from witnesses, and specifically I can think of two witnesses who were gay, was the question of the age at which it is reasonable within the school setting to be discussing orientation. I think certainly both of those witnesses were of the opinion that as far as they were concerned sex education was non-existent. One of them was a young teenager, so he has had fairly recent experience. At what age would you think it reasonable to expect a school to be discussing the issue of orientation, bearing in mind that one of the witnesses said he felt that he would have been helped had it been addressed in primary school?

(Mr Twigg) Clearly it is an area that needs to be handled with sensitivity. Certainly I think it is right to say that in primary school it is proper that there is an awareness of the different forms of orientation, different forms of sexuality, different ways in which people live their lives.

But at the moment that is not taking place, is it?

(Mr Twigg) Mostly it is not. I think there are positive examples where it is happening and where it is handled in a sensitive way in the school with the support of parents, but I do not think that is the norm and it is an area where we need to do more work. The health in schools programme, Safe for All, is providing training for teachers on a number of issues, including around sexuality and homophobic bullying. That has been a very positive example of the Department of Health and the Department for Education and Skills actually working together. The guidance that we issued in 2000 does give encouragement to schools to deal with questions about sexuality in an open and honest way and really that is what has not been happening in the past and still is not happening in many schools and is where further work is required.

Jim Dowd

Reference has been made by other colleagues to our visit to Sweden, Stockholm in particular, and I am sure both of you are familiar with the approach they have there through youth clinics, which although they seem to be on a semi-statutory footing seem to work fairly well, certainly the ones that we saw around the Stockholm area. Is that an area for further development between schools and health services? Are there plans to do so?

(Mr Twigg) I think very much so. I referred to the extended schools programme and the aim there is to have on a school site a lot of other facilities that make the school much more a hub of the community and not simply a place of learning for the school age children. Twenty of those 25 projects have a health service element within them and bring some of the benefits that Hazel was describing earlier on. The other area which I think is relevant here is our Connections Service which seems to bring together all of the different agencies that 13-19 year olds are working with and I think issues to do with health, including sexual health, are an important part of what would be a successful Connections Service. That is happening in some cases. I know you went to Paignton and saw the Tic Tac Centre ----

We are going.

(Mr Twigg) Actually the Devon and Cornwall Connections Service has been one of the most successful in really bringing together some of the different agencies and not simply being a replacement for the Careers Service.

(Ms Blears) That is the intention, that we develop more of these facilities. Of the ones that are in place now the feedback is tremendously encouraging. I think you have to be aware that although people do want to access services at schools, we then need to have confidentiality and trust and the fact that going to have a personal one-to-one consultation with the school nurse is not going to be done in the full glare of the rest of the school, therefore handling those issues with sensitivity is extremely important. People really do value having a range of primary care facilities in the schools environment as well but we have to handle that with sensitivity.

Jim Dowd

The clinics that we saw in Stockholm were all off-school sites.

(Mr Twigg) That is different.

A slightly different approach. One of the other points referred to by the Chairman as well was in Sweden, in the Netherlands, in the places you mentioned yourself just now, they seem to have a different attitude, the parents talking to their children. Although all the evidence on this is anecdotal, most people in Britain seem to think we are particularly bad at this. Are either of your departments doing anything to attempt to redress this, even though I am sure it may be very deeply culturally entrenched, or do we just accept that as an inevitable fact of life?

(Ms Blears) I think one of the important things that we are trying to do with our sexual health campaign is to be more overt in saying these are important issues for the whole community and providing points at which people can enter into discussion about it you create a talking point and, therefore, it becomes a more normalised thing to talk about amongst the generations and amongst the wider community. I think there is a history in this country of almost having hidden some of these issues and that is partly why GU services are sometimes around the back of the hospital in a very isolated place, there was a view that you could not be seen to be using these services, it was not a normal part of the NHS. I think that we have got a long way to go on bringing these services into the mainstream. There is a cultural issue and finding hooks on which parents and children can enter into a discussion, maybe through reading an advertisement, maybe seeing something on the television, that then promotes that kind of conversation is incredibly important, I think. We are encouraging Parent Line's own campaign which is encouraging parents to talk to their children about some of these issues. It is difficult but I think as the generations grow up who have had access to really good sex and relationships education then we hope to be laying the foundation now for future generations not to be embarrassed and to be able to discuss these things with their families.

(Mr Twigg) I think from an Education Department point of view this actually is a broader question about how we can engage parents more effectively in terms of schools. There is a great deal of evidence that some of the most successful programmes in tackling under-achievement in schools are those which go out of the school and work with parents and work with the wider community. I would put that in this context, that it is one of the number of ways in which we look at greater parental involvement. As I mentioned before, the Ofsted report places particular emphasis on the issue of boys and I noticed from your evidence last week that a lot of the boys feel that sex education primarily is not aimed at them, it is aimed more at girls. That is something that we are addressing at the moment. We are doing some work with the National Children's Bureau where we are going to have new, detailed guidance for teachers which will be available later this year looking at a number of aspects, sexual health, parenthood, but in particular looking at how we can engage boys in sex and relationships education. We also have as a broader campaign in the Department our Dads and Sons campaign which is to do with engaging fathers in their sons' education and as part of that we have addressed through the website and the magazine that we publish issues around talking about sex and relationships father to son.

Chairman

In a sense you have taken me on to the next question because I wanted to ask you what work was being done in relation to boys and men. It is very apparent that we have a huge problem in getting men to engage with the system at all. You have partly answered the issue on education and I wonder whether you have any initiatives relating to sport? I was very impressed with a project that was on testicular cancer that involved someone very close and it was a very effective way of projecting this as an issue. In a sense it was a very effective way of attracting attention. I wonder whether you are looking at the way men may be more influenced by approaches, shall we say, outside the mainstream, mainly through sport, or other ways of attracting their attention?

(Ms Blears) We are currently funding the Men's Health Forum to do work on a whole range of men's health issues and they are particularly looking at ways in which you can engage men. One of the publications that they have just produced - I do not know if Members have seen this - is along the lines of a car manual. It is a manual about the body and they have done it in terms of, if you like, the engine, the lubrication system and the chassis, looking after your body. It is the most brilliant publication. It is like a Haynes Manual, done in exactly the same way that you maintain your car but this is about how you maintain your body. It covers sexual health and a whole range of issues. I think it is one of the most effective pieces of health promotion work that I have seen in a long time. With our sex lottery campaigning we are also placing adverts in magazines particularly designed to appeal to young men. We have got a number of projects going on where we are trying to take health promotion work out to pubs, to football matches, to places where you can engage with men in a non-traditional setting. I think traditionally men have not been good at going to the GP, going to the doctor, looking after their health, and I think we have a huge amount of work to do on this to get men to really want to look after themselves a bit better.

One of the areas that I am aware of that is going to affect male access to health is the recruitment to medicine which, as you well know, is in the main female. The majority of people in the country gaining training are women. I imagine most of the men that I know, if they had some sexual problem would not want to see a woman, but maybe I am wrong. There are one or two dissenting voices on the Committee. Maybe we have some cultural differences and geographical differences. Let me tell you, in my part of the world I reckon that the majority of men would be much more comfortable, and we have got evidence that a third of men suffer from some form of erectile dysfunction, if it was something of that nature perhaps talking to a male doctor. What policies are you considering to address this as an issue if you have got more and more women doctors? I welcome that because I think the boot has been on the other foot for too many years where women have had to talk to male doctors.

(Ms Blears) In the past it has been the reverse problem in that it has been difficult to get a female GP.

Absolutely.

(Ms Blears) Therefore, solutions have been brought forward to have more nurses, practice nurses, more health care advisers and I think the same is true in relation to where there are only female GPs and attracting more men into a wider range of health service professions is increasingly important. I am not aware of any specific evidence that says that men on sexual health matters would simply want to talk to men. I would be quite interested to look at some of that evidence and whether or not they find it easy to talk to women as well. That would be quite an interesting area to explore. I think we do have a duty in the NHS to try to ensure that if people, with whatever problems they have got, want to have access to a particular gender of health professional we must do our very, very best to ensure that happens because unless we get the consultation right then we do not get the outcome for the patient at the end of the day. I am not aware that there is an overwhelming number of all-female GP practices in the country at the moment but clearly perhaps this is an issue that should be on our horizon for future development.

Dr Naysmith

One of the factors that young people themselves raised with us was the strong influence, they said, of alcohol on sexual health related diseases. You only have to wander around any city in this country at about 11 o'clock on a Saturday night, nowadays most nights, and you can see fairly clearly that there must be some sort of link there. There is obviously peer pressure as well. Especially since we have got the Minister for Alcohol here with us today, I just wonder is there any research going on to look at this, especially in the context that we are slackening off and relaxing licensing laws as a matter of policy?

(Ms Blears) I am actually the Minister for Sex, Drugs and Alcohol. The only thing I do not have is rock and roll.

Jim Dowd: That is typecasting.

Dr Naysmith

It is certainly something that we need to take a great deal of interest in. Is there any research going on in that area?

(Ms Blears) It is a very interesting area. The proportion of young people between the ages of 11 and 15 who drink has actually remained at roughly about the same over the last decade or so, around about a quarter of them.

Chairman

How does that break down male to female? Certainly my impression is that a lot of young women are drinking far more than used to be the case.

(Ms Blears) I think that is the case but that is amongst the older teenagers, if you like. Amongst the very young people between 11 and 15 about a quarter of them are drinking. The worrying issue is that when they were drinking initially, ten or 12 years ago, they were drinking about five units a week but that has gone up over the last ten years to about ten units a week, so they are actually drinking more, or there were not more of them drinking but the ones who were drinking were consuming more. I think that evidence is quite clear. When you look at their reasons for drinking they are the same as everybody else's: to relax, to relieve stress, to be with their friends, to get a buzz and have a good time. The evidence is not clear about the links with risky sex behaviour. It is still not a clear picture. Obviously we are now engaged in the cross-government alcohol harm reduction strategy, so we have not commissioned any new research at the moment because we want to see what comes from that consultation process in terms of the links between alcohol, sex and drugs as well because I think all of these are evidence of different kinds of risk taking behaviour and the project on alcohol harm reduction that we have should produce some very interesting observations for us to look at in developing our longer term policy. Members will be aware that the licensing policy is really around the issue of trying to make sure that we do not have fixed determined hours when everybody comes out of the same club and causes the kind of anti-social behaviour that we have seen in many of our cities, and therefore we hope that having some staggered hours is going to result in less of that kind of behaviour. The things we are identifying at the moment are binge drinking and increased drinking amongst young people and increased drinking amongst those and older teenage young girls as well. These are very important issues for us.

Dr Naysmith

Moving on to the older teenage girls, because we are interested in sexual health in its wider context, not just teenage pregnancy, do you think it does have an effect? Is there any evidence of this?

(Ms Blears) I am not aware of any evidence that has specifically looked at the links. If you look at the number of young women under 20 who have now got chlamydia I think it is something like over 30 per cent of young women over 20, which is a very interesting statistic, but I am not aware of any specific research that has linked that with the increasing consumption of alcohol. We could all form our own anecdotal views, I am sure, but I do not know of any existing research on that issue.

Chairman

Can I ask a question about the role of the media and its impact on children and young people. It was very apparent from the young witnesses we had last week, and we had this when we were in Manchester when we met their Young People's Council, that media projects sex morning, noon and night in terms of the images that they see and yet the overt message about dangers, responsibility, relationships, does not come out. I have a teenage daughter who watches Coronation Street, Emmerdale and Eastenders. Some of the stuff that you see on these programmes projects quite a worrying picture of society which I think young people are seeing very much as the norm and perhaps wanting to get into. That is the message that we have got from some of the witnesses we have talked to. Do you see that government has a role in addressing this as a wider issue in the way that programmes such as Coronation Street and the others portray life when the life of people is often very different and the apparent models that are offered to kids are wrong?

(Mr Twigg) I am always very sceptical of politicians launching in and commenting on these sorts of things. I tend to think when talking to young people that whilst young people recognise that there is that, and it clearly shows in your evidence from Manchester, the majority of young people are actually pretty sussed and sophisticated about these things and can see through that and they might just think it makes bad television that that is the sort of focus that Eastenders or any other programme has got rather than that they are that powerfully influenced by it. I think we have a role through education to do the things that I have talked about, working together with health, but I would be wary of us saying we want to start looking at the content of television programmes.

I am not saying that. What I am trying to say is that we are not getting the other side of the story across. That was the message we were getting from the young people. I was struck by the Health Minister's comment earlier on that if we get the next generation of parents looking at this more responsibly then that will have an effect in the future. I hope you are right but my worry is that by then the media influence will be even more negative on young people, so perhaps we are going to be a long way behind at each stage the wider influences that are affecting young people's behaviour.

(Mr Twigg) One of the things that citizenship education is doing is actually encouraging young people to look very critically at the role of the media. I remember going to visit Deptford Green School in Lewisham, which has really pioneered excellent citizenship education, and one of the things that the young people have been doing specifically is looking at press coverage, looking at media coverage, and having a critical input into that. I do think that is something important that we need to encourage to be happening more widely.

(Ms Blears) I think this is a priority for the whole of government, not just for health or for education but for all of us in trying to build strong communities. That is a big strand through all of our neighbourhood renewal and regeneration initiatives. If you look at the correlation between social class and some of the problems that we have been talking about today, it is very apparent that people from poorer communities and from some of our black and minority ethnic communities have got specific difficulties and specific issues here and, therefore, building those stronger communities and a framework in which people really feel that they are valued, that they can make a contribution and make a difference, I think is how we build a different set of values in our community. I do also think that role models are important. To do as much as we can to try and get some of our people helping us with some of our messages is a legitimate thing for us to do. I am always very wary not to be the nanny state minister, I do not want to be that, but on a whole range of public health issues trying to give people information so they can make the right choices is absolutely my responsibility. I have got to make sure that they have got the information, the leaflets, the views, as much access to that as I possibly can so that the people themselves are empowered to make some of those different choices and perhaps to resist some of the pressure that is out there through the media that they are bombarded with on a day-to-day basis.

(Mr Twigg) Can I say something in defence of the media because I think some of the soap operas have been very good in terms of dealing with some of the difficult issues.

(Ms Blears) Yes, they have.

(Mr Twigg) I remember covering the storyline in Brookside about sexual abuse within the family, which I thought was handled incredibly sensitively. I think the Colin character in Eastenders as the first openly gay character in a television programme probably did more to give confidence to a lot of younger gay men in particular than anything that we as politicians may think of.

Chairman: I think perhaps the one that I object to most is Emmerdale which portrays a view of rural Yorkshire that I certainly do not recognise. There are too many southern accents in it for a start.

Dr Naysmith: You used to be able to listen to The Archers but you cannot do that any more.

Chairman

On the issue of last week's evidence, I had an interesting letter from a lady in either Suffolk or Sussex, I cannot remember which, somewhere in the South of England, who had heard the coverage on Today in Parliament and she was saying that she objected to the strong regional accents that came over. I could bring the letter along. She made the point that the Committee did not appear to address the moral framework of sexual relationships. It has certainly struck me in this inquiry that we need to be looking very carefully at how we offer education in the future on relationships within a moral framework because I have been very worried by the evidence we have received that there is evidence out there - I never thought I would hear myself say this - that people do not appear to have any sense in some instances of sexual responsibility, particularly people who are infected. Some of the evidence we picked up in Manchester was very worrying where people were infected and continued to practise unsafe sex. Do you feel that the government has got a role here both in terms of the education system and in terms of the Department of Health? How do you balance that role with not being nanny state-ish in the way that you described a moment or two ago?

(Mr Twigg) We certainly do have a role and it is an important part of our job in education, the job of schools, and the guidance that was issued in 2000 places great emphasis on the moral framework in teaching about relationships, it places central emphasis on marriage, without seeking to be exclusive about it, and sets out the benefits of marriage to our society and the stability of our society. I think all of this work has a very powerful moral underpinning and effective early sex and relationships education, going back to what we spoke about earlier on, can bring benefits in terms of the strengthening of communities that Hazel was talking about. Some of these issues, whether it be sexual diseases or teenage pregnancies, harm communities and, as Hazel said, they particularly hit some of the poorest communities. I think there is a very, very powerful moral dimension to this that we should not in any way be frightened of. Young people expect us to have that moral dimension, they do not want us to be nanny-ish, they want us to give them information, they want it to be at an appropriate stage. I do not think young people have a problem at all with us saying that there is a clear moral character to these issues.

(Ms Blears) I think as well particularly in the area of HIV in terms of the gay community, we have got research that shows very clearly that people want to have good quality information and, therefore, working with the voluntary sector we are much better able to produce realistic stuff that is not patronising, that is not nanny-ing, that talks about the reality and I think that is very important. That is why we work so closely with the Terrence Higgins Trust, the National Aids Trust and the Chats Programme, which is internationally recognised as having good quality information. Importantly, part of the counselling that we do with people in those circumstances is about the dangers of transmission, about the effect that you can have on other people, not just your own health but the wider community as well. Getting time in the system to be able to do that counselling and that support work is absolutely crucial to that moral framework that says we do not live just as isolated individuals, all of our actions have an effect on other people and there is nowhere that that is more important than in terms of sexually transmitted infections and making sure that we can trace partners and provide them with support, that is very important indeed.

Jim Dowd

Going back to the point you mentioned, Chairman, about men's health, I was very interested in what you said. I heard a clinician on the radio the other day saying that most men look after their cars better than they do their own bodies, so I was very interested in your Haynes Manual approach. We have had evidence here from somebody who said that most men go to the GP for their last immunisation jab and the next time they present themselves is at A&E after their first cardiac arrest. Is the issue really not getting men to see male doctors or female doctors but getting men to see doctors of any kind?

(Ms Blears) I think there is a cultural thing that it is almost a sign of weakness, I suppose, if you go and get health care. It is about education and I think people coming through the system realise that it is right to keep a regular check, using the motoring analogy, to get your MOT on a regular basis and that keeps you fit and healthy. Probably amongst older men it may be more of a problem, I think younger men coming through will access health services more. With the development of NHS Direct, on-line, kiosks, using technology, in some cases, not all of them, men would much prefer to get access to a computer or talk to a helpline than necessarily face-to-face consultations. Providing a variety of ways in which men can access the health service I think is something that we do really want to explore and we are increasingly beginning to do that now.

Chairman: The other point on access that came over last week was the potential of texting for young people to access advice. If you have got teenage children they are constantly on their mobiles.

Sandra Gidley: The mention of computers reminds me of something that was said last week, that kids in the schools cannot actually log on to sexual health websites because as soon as the word "sex" comes up everything is screened.

Chairman: It is the same with the PDVN here, I have noticed.

Sandra Gidley

Is there some way of looking into that because I think it is important? If young people are comfortable with that technology, they may not have a PC at home and I think it is important that they should be able to do it at school.

(Mr Twigg) I had no idea of that. I will look into it and I will come back to you and the Committee about it.

Chairman: Are there any further questions? If not, can I thank both of our witnesses for an excellent session, we are very, very grateful. I hope the report that will be coming out in the near future will be of help. Thank you.