Select Committee on Health Third Report

Conclusions and recommendations

1.  We are concerned that it took at least seven weeks for the Deputy Head of the Sexual Health Policy Branch at the Department of Health to realise that the Department had been sent key data on sexual health which it had commissioned, and that the responsible Minister had not seen this data in advance of her appearance before the Committee. We are also surprised by the air of secrecy which surrounds this research, and can only surmise from this that it contains findings that would be unwelcome for the Government. If the Government places any value on the scrutiny work of Parliament, and takes seriously its commitment to co-operate with the work of Select Committees, it would seem counterproductive to withhold the most up-to-date information on sexual health services from the Health Committee when it is conducting an inquiry into precisely this subject. (Paragraph 14)

2.  We welcome the Government's adoption of our recommendation of a 48-hour access target for sexual health services. However, the Government should take note of the warnings we have been given by clinicians that this target may not be achieved within the timeframe specified by Government without additional spending, and that inadequate facilities may present a barrier to service expansion. (Paragraph 23)

3.  We also welcome the Government's adoption of our recommendation for a dedicated health education campaign aimed at improving sexual health. However, the Government should not begin the campaign until it is certain that services have the extra capacity they need to meet the extra demand the campaign will generate. (Paragraph 24)

4.  We welcome the extra investment for GUM services of £130 million over three years, but evidence submitted to our previous inquiry into sexual health suggested that the true funding needs of GUM services may be far greater than this. Estimates provided by the Association of Genito-urinary Medicine suggested that around £150m of capital funding alone would be needed to modernize GUM facilities, and on top of this we were given evidence of the need for up to £30 million per year additional revenue funding for GUM services, giving a total of some £240 million. The Government should keep the funding of GUM services under close review and be prepared to increase allocations if this should prove necessary. (Paragraph 28)

5.  We welcome proposals to improve performance monitoring around sexual health. However, we remain very concerned by reports that previous allocations for GUM services, when filtered through PCTs, often did not reach the services for which they were intended, but were siphoned off to fund services identified by PCTs as being of a higher priority. To ensure that this does not happen again, we recommend that, at least for the next three years, the Department supplement its existing performance management of sexual health services by commissioning a specific financial audit to check that funding has reached its intended destination. The audit could be carried out by the Audit Commission or the Healthcare Commission. The results of the audit should be published to identify any funding gaps that may occur. (Paragraph 34)

6.  The Department, in its response to this Report, should also supply us with a detailed breakdown of the £300 million funding for sexual health services, specifying whether the funding is entirely new, or is part of the total funding for PCTs already announced, as implied by the Minister. (Paragraph 35)

7.  Both men and women should be screened for chlamydia. We are concerned that current efforts to screen men are insufficient. Furthermore, by introducing the cut-off for the screening programme at 25 year-olds the Government also risks missing a significant proportion of young people who remain vulnerable to chlamydia infection and its consequences. We therefore recommend that the national chlamydia screening programme be extended to men as well as women, and that the target age range be extended from 16 - 25 year olds to 16 - 29 year olds, at least initially. If it is subsequently shown that chlamydia screening is beneficial across a wider age range than this, the Government should extend the programme accordingly. (Paragraph 43)

8.  In addition, we note that there are limits to what can be achieved by an opportunistic screening programme, which relies on people seeking out healthcare services for another reason, such as contraception, rather than proactively inviting them to attend for a test. This may pose particular problems in screening young men, as research suggests that young men generally attend health services less frequently than women. We therefore recommend that the Government monitors the rates of chlamydia infection closely to assess the effect of the national screening programme, and that, if rates of chlamydia continue to increase, it considers supplementing the opportunistic screening programme with a proactive call-and-recall system targeting specific high-risk groups. (Paragraph 44)

9.  It is unacceptable that a test is still being used for chlamydia which may miss as many as 30% of infections, when a far more accurate test is available. We are pleased that the Government is to make NAA testing available in all areas, but disappointed that this will not happen until 2007. Some clinicians even doubt that this target can be achieved. The Government will need to monitor this target carefully over the next two years to ensure that NAA testing is, indeed, universally available in all clinical settings by 2007. (Paragraph 48)

10.  We are disappointed that the Minister does not appear to share the view of many leading authorities in the area of sexual health that primary care services are a huge untapped resource for delivering sexual health services, and crucial to improving the nation's sexual health. Indeed, the Government's own Strategy on Sexual Health and HIV set out a key role for GPs. While we do not want to downplay the potential role of community pharmacies, it is clear they are unable to provide the same level of service as a GP or a specialist sexual health clinic. Moreover, most community pharmacies are not yet in a position to be able to offer sexual health services. By contrast, most of the population is registered with a GP, and GPs currently provide 80% of contraceptive services. Consequently, GPs are uniquely well placed to offer opportunistic screening or health promotion advice in the area of sexual health. (Paragraph 58)

11.  The initial negotiations over the GP contract were a wasted opportunity to mobilise GPs to tackle sexual health. We are therefore pleased to hear from the Department of Health official that a formal review of the GMS contract will take place. We recommend that the Government and the BMA review the contract as soon as possible. We further strongly recommend that the Government negotiates for the inclusion of sexual health services within the "Essential Services" or "Additional Services" headings of the contract, with the introduction of quality points to encourage GPs to provide these services. (Paragraph 60)

12.  We are pleased that the Department recognises the advantages of GPs undertaking chlamydia screening. We recommend that the Department makes provision for such screening when it reviews the GP contract. (Paragraph 63)

13.  In our previous inquiry, serious concerns were raised about shortages of consultants who specialise in sexual health. Our evidence suggests that the situation is little improved since then and that it may be necessary to provide sufficient consultants to deal with an expected increase in GUM patients of between 30-50% before 2008. We recommend that the Government takes account of this in its workforce planning. (Paragraph 67)

14.  It is essential that GPs and practice nurses are properly trained and supported to provide sexual health services. We therefore recommend that the Government develops a sexual health training programme for primary care clinicians, possibly modelled on the successful training programme for the primary care management of substance abuse. This must be funded by a dedicated training budget. (Paragraph 68)

15.  We recommend that the Government takes steps to promote and facilitate better joint working between GUM and family planning services, in order to move towards the integrated model of sexual health services set out in its National Strategy for Sexual Health and HIV. This should include addressing any potential difficulties which may arise through new funding and purchasing arrangements. (Paragraph 71)

16.  We are pleased that the Government has accepted our recommendation to conduct an audit of contraceptive services, with attached funding to rectify any problems, and that this audit will include GP contraceptive provision. We look forward to receiving the results in due course. We recommend that the Department, in its review of the GP contract, consider introducing incentives for GPs to deliver higher quality contraceptive services. (Paragraph 74)

17.  We are surprised that although the White Paper devotes an entire section to sexual health, it does not discuss abortion services. They are an important aspect of sexual health services, as the Government's 2001 Strategy acknowledged. It is crucial that the Government retains the National Strategy for Sexual Health and HIV's target that from 2005 commissioners should ensure that women have access to abortion within three weeks of the first appointment with the GP or other referring doctor. The Healthcare Commission should also retain its PCT performance indicator of the percentage of NHS-funded abortions performed under 10 weeks. (Paragraph 77)

18.  We welcome the acknowledgement by the Department for Education and Skills that Personal Social and Health Education (PSHE) and Sex and Relationships Education (SRE) lessons are far better taught by specialist teachers than by form tutors, and are pleased that increasing numbers of teachers are completing specialist training to becoming accredited PSHE teachers. However, we remain deeply concerned that, by DfES's own admission, in the majority of schools PSHE and SRE lessons are taught by form tutors rather than by specialist teachers. We therefore recommend that the DfES issue specific guidance to schools stipulating that by 2007 all PSHE and SRE lessons must be taught by specialist accredited PSHE teachers rather than by unqualified form tutors. These teachers should build up and maintain links with clinicians working in sexual health, including community nurses and GPs, who can often contribute very usefully to SRE but who should not be used as a substitute for a qualified SRE teacher. (Paragraph 86)

19.  We are disappointed that, despite a report from its own schools inspectorate stating that a major weakness of PSHE is its current lack of assessment, and the fact that it is often afforded insufficient time and priority within the school curriculum, DfES is unwilling to make PSHE and SRE a statutory part of the National Curriculum. The costs and consequences of this ill considered decision are considerable. We again recommend the establishment of PSHE and SRE as statutory and assessed parts of the National Curriculum. (Paragraph 89)

20.  It is very important that the UK does not become a magnet for HIV+ individuals seeking to emigrate to this country solely to access free healthcare. However, neither the Department nor any other interested parties have been able to present us with any evidence suggesting that that this is currently the case, or that the introduction of these restrictions on free treatment will actively discourage people from entering or remaining in this country illegally. What little evidence exists in this area in fact seems to suggest that HIV tourism is not taking place. It suggests that HIV+ migrants do not access NHS services until their disease is very advanced, usually many months or even years after their arrival in the UK, which would not be the expected behaviour of a cynical "health tourist" who had come to this country solely to access free services. (Paragraph 111)

21.  We have received evidence that NHS staff are finding it very hard to implement the new regulations in so far as they affect HIV patients. Because of the highly confidential basis on which they are run, sexual health and HIV services may be reluctant to give overseas patient managers access to their patients, meaning that the difficult job of determining eligibility falls to doctors or receptionists. Receptionists are unqualified to make the clinical decisions that may be necessary to determine whether a person needs free treatment; and doctors, when required to adopt a "gatekeeper" role in determining a patient's eligibility for free treatment, feel an irreconcilable conflict with their primary duty to care for the patient. (Paragraph 120)

22.  During oral evidence the Minister answered almost all of our arguments by repeating that, although HIV treatment is no longer free for people living in this country without proper authority, "there is still provision for easement by individual clinicians under individual circumstances, and at the end of the day, the decisions are the clinician's". We have not seen any evidence to suggest that the Department intended the clause for "immediately necessary" treatment to allow clinicians to provide free routine HIV care to all HIV+ patients, regardless of eligibility, and nor does our evidence suggest that clinicians and Trusts are interpreting the regulations in this way. If it is the Department's intention that the regulations be interpreted this way, we recommend that it issues guidance to this effect immediately. However, we do not believe that the Department does intend the regulations to be interpreted in this way. Rather, it seems that regarding HIV, this easement clause provides clinicians with only very limited flexibility to provide treatment for ineligible HIV+ patients once they become severely unwell or their immune system is significantly weakened, rather than enabling them to prevent this deterioration in the first place (Paragraph 125)

23.  The Department's consultation on changes to charging rules for overseas visitors suggested that cost-saving was a key reason for reviewing the regulations. We were therefore astonished that, by the Department's own admission, these changes have been introduced without any attempt at a cost-benefit analysis, and without the Department having even a rough idea of the numbers of individuals that are likely to be affected. While generating even small amounts of savings for the NHS might appear to be worthwhile, in the case of HIV treatment we have received powerful evidence that it would in fact be more cost-effective to provide free HIV treatment to all, as, without treatment, HIV+ individuals living in this country without proper authority are likely to place a far greater burden on NHS resources. We recommend that the Department reviews the financial implications of this policy immediately and, furthermore, that it ensures all its future policy decisions are based on evidence and underpinned by robust cost-benefit analyses, as stipulated by Cabinet Office and Treasury guidelines. (Paragraph 138)

24.  In its cost-benefit analysis of the changes to regulations governing access to free NHS treatment for overseas visitors, the Department must also take into account the potential costs associated with increased onward transmission of HIV. (Paragraph 139)

25.  We were surprised to learn that no public health impact analysis of these regulations was carried out prior to their enactment, particularly given the level of the public health threat posed by HIV and the increasing rates now being seen in this country. We are aware that public health arguments were put to the Department during its consultation, but these arguments do not appear to have been answered or taken account of. Given the Department's responsibility for safeguarding public health this seems short-sighted, and suggests a lack of coherence within policy making within the Department. We recommend that, in addition to cost-benefit analyses, public health impact analyses be carried out in respect of all Department of Health policies. (Paragraph 145)

26.  We are unable to share the Minister's optimistic view that the introduction of charges will have no impact on the numbers of people coming forward for HIV testing. Although charges have been in place for less than a year, the fact that organisations such as the Terrence Higgins Trust are already reporting a growing reluctance to have HIV tests amongst migrant communities is extremely worrying. (Paragraph 151)

27.  Coupled with increasing confusion regarding eligibility for HIV treatment even amongst those who are eligible, and fear amongst migrant communities that if, in future, they attend health services they will be questioned about their immigration status, this strongly suggests that the introduction of charges for HIV treatment will increase the number of HIV+ people living in this country who are unaware of their infection, in direct contradiction of the Government's target to reduce the number of undiagnosed HIV infections. An increase in the numbers of people who are unaware of their HIV+ status will pose a serious and escalating threat to public health. (Paragraph 152)

28.  The evidence refutes the Minister's stance that anti-retroviral treatment does not reduce HIV infectivity and therefore has no impact on public health. On the contrary, the scientific literature to date suggests that HIV infectivity is directly linked to viral load, and therefore that treatment which reduces the viral load of HIV+ individuals will potentially reduce onward transmission of HIV. Indeed, the Health Protection Agency, the Government's own public health advisory body, stated unequivocally to us that "if you do not treat individuals and they remain in this country and are sexually active in this country, then the transmission is bound to go up." (Paragraph 161)

29.  While we accept that, in giving evidence to us, the Public Health Minister was not supported by a Department of Health official with medical expertise, we are surprised that she appeared so unbriefed on basic aspects of public health prevention. Firstly, many treatments do not reduce the risk of onward transmission to zero. This is the case for genital herpes and for TB, both of which are exempt from treatment charges on public health grounds. Secondly, it is worthwhile reducing the risk of onward transmission of a disease, even if it cannot be eliminated. (Paragraph 162)

30.  We welcome the Department's statement that hospital maternity services should always be considered immediately necessary treatment, including, where necessary, HIV treatment. However, evidence presented to us suggests that considerable confusion exists over eligibility for maternity services. If the charging regulations are extended to encompass GP services, this situation is likely to worsen, as primary care is a key access point for ante-natal services. We recommend that the Department immediately issue further guidance to the NHS stating that antenatal and maternity services, including HIV treatment to prevent mother-to-child transmission, must be made available to all women, regardless of their immigration status or ability to fund the treatment. (Paragraph 166)

31.  We are extremely alarmed by the prospect of people co-infected with HIV and TB being managed ineffectively. If their underlying HIV is not treated because of cost, they may then default from care and as a consequence transmit TB to as many as 15 people a year. It is a nonsense that the Government is prepared to fund a person's TB treatment on public health grounds but not treatment of his HIV infection. (Paragraph 171)

32.  Primary care can be a vital access point for all types of services. This includes services which the Government stipulates must continue to be provided free to all people, regardless of their eligibility status, such as HIV testing, treatment for communicable diseases such as TB, antenatal and maternity services, and "immediately necessary" treatment for emergency problems. Refusing patients free access to GP services could, arguably, be seen to undermine all these exemptions that the Government has made within the charging regime by denying patients access to a first, basic health assessment. We therefore recommend that all people, regardless of their eligibility status, are given access to a free primary care health assessment. (Paragraph 174)

33.  We are deeply concerned that neither the Department nor the Public Health Minister appear to have considered or understood the public health implications of refusing HIV treatment to people who, although not legally resident, continue to live in this country. Firstly, it seems that this policy is already deterring people in high-prevalence migrant communities from accessing HIV testing. Equally importantly, by denying people free HIV treatment, a vital opportunity is being missed to reduce by perhaps as much as 60% their likelihood of transmitting HIV within the wider resident population. We dispute the Minister's view that HIV treatment benefits only the person receiving it, and her view that for a public health intervention to be worthwhile it must reduce the risk of onward transmission to zero - TB and genital herpes are just two examples of communicable diseases for which treatment is currently free where a significant risk of recurrence and onward transmission remains despite a course of treatment. We also have serious concerns about the impact of this policy on mother-to-child transmission of HIV, and of the onward transmission of TB, including drug-resistant strains. (Paragraph 175)

34.  During our evidence session, the Minister mentioned the "easement clause" the Government has introduced, which enables clinicians to provide treatment deemed to be "immediately necessary" regardless of a person's eligibility status. In a subsequent letter she also further emphasised the clause which states that where a person has begun a course of free NHS treatment, that treatment will continue to be free until the course of treatment has been completed. According to the Minister, "for HIV in many cases this will mean treatment will continue free of charge for a very long time". While we appreciate these attempts on the Government's part to reduce the impact of the regulations on those who have life-threatening problems or who have already begun treatment, we feel that they do not adequately address the problems that we have identified in respect of HIV. (Paragraph 176)

35.  We agree with the Minister that it is appropriate to provide a national health service, not a global one. However, a crucial part of the Government's responsibility to provide a national health service is to protect the health of the population. Untreated HIV+ people living in this country present a serious public health threat, and we therefore recommend that all HIV+ people, regardless of their immigration status, receive free treatment to reduce the likelihood of the onward transmission of HIV, of mother-to-child transmission of HIV, and of the onward transmission of TB. We believe that to achieve this, HIV should be reclassified as a Sexually Transmitted Infection, which would make treatment automatically free on public health grounds. If, subsequently, there is evidence that as a result of this decision the UK is becoming a magnet for HIV+ people around the world seeking access to free treatment, which from the evidence we have heard we do not anticipate, the policy can be reviewed. (Paragraph 177)

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