APPENDIX 3
Memorandum by The British Association
for Sexual Health and HIV (HA 4)
CONSEQUENCES OF
THE NEW
PROPOSED CHANGES
IN CHANGES
FOR OVERSEAS
PATIENTS WITH
REGARD TO
ACCESS TO
HIV/AIDS SERVICES
Summary
HIV positive patients in the UK irrespective
of immigration status are of public health concern. Those that
are seeking asylum or have undetermined status are often extremely
vulnerable with complex needs requiring health care appropriate
to their medical condition. The new and proposed changes in charging
may result in increasing discrimination, discouraging people coming
forward for testing at a time when the health agenda is to seek
to identify those who are unaware of their status. Increasing
barriers to individuals who do have entitlement to free treatment
for other infectious diseases is an unwanted outcome. Other possible
consequences include greater cost to the public purse through
ongoing transmission of infection, including to unborn children
and for emergency medical treatments due to complications. This
raises questions about the public health implications of denying
certain groups' access to health services and places clinicians
in difficult ethical dilemmas. Charging for overseas patients
is unlikely to deter people from seeking asylum, or encouraging
those refused to return to their countries of origin. An opportunity
to reconsider these changes is welcome.
1. There are humanitarian and human rights
concerns in the application of changes to the regulations. A clinician
asked to care for foreign national with a possible communicable
disease ethically should treat everyone according to their assessed
clinical need. Doctors recognise that providing antiretroviral
therapy for HIV is expensive but whilst there maybe a short term
cost reduction to local NHS budgets, in the longer term the overall
cost to the public purse, public health and the individual may
be greater. Several days in intensive care because of an emergency,
life-threatening infection is more expensive than a year of antiretroviral
therapy.
2. Reducing the risk of onward transmission
of infection and the risk of progression of infection is paramount
to using health care resources effectively. There is an irrefutable
argument to prevent mother to child transmission of HIV to unborn
children. This requires all HIV positive mothers to be offered
antiretroviral treatment. After birth, free formula feed must
be provided to avoid breast milk transmission.
3. The change in regulations may influence
people within communities of high prevalence to come forward for
testing if they are unable to obtain treatment. There is also
the danger of misinterpretation of the regulations to refuse treatment
to those who are entitled.
4. There are potential differences between
clinics according to interpretations of the regulations that fuel
health inequalities.
5. Those cases admitted as emergencies are
not always made aware of possible subsequent charges. Many of
these people are unable to pay. They have no legal means of employment
and are effectively destitute which means that billing them is
a waste of time and money. Further stress is placed upon already
unwell individuals.
6. It is difficult ethically and clinically
to separate HIV from other sexually transmitted infections, and
other contagious diseases such as TB for which free treatment
is provided.
7. Should the Home Office decide that the
person is to be removed from the UK, even a short time on antiretroviral
therapy may provide benefit. In such cases patients should have
a detailed summary of their medical care and treatment in the
UK that can be given to care providers in their destination country.
Preferably medication should be provided for a minimum period
of time from the date of their removal. Patients should be advised
properly how to stop therapy if that is the outcome to reduce
risk of viral resistance developing.
Conclusion
8. People with HIV who are unable to access
antiretroviral treatment and other services will remain in the
community and be more infectious than with treatment. There will
be less opportunity to support safe sexual behaviour and avoidance
of onward transmission.
9. Discussion of charging regulations may
discourage people including some entitled to free NHS services
from coming forward.
10. The effort and resource required to
bill people for care and treatment, who are unlikely to be able
to afford it is wasteful. This may also fuel fears of unfair discrimination,
risking delayed presentation for testing and increased vertical
and horizontal transmission of HIV in the UK.
11. Clinical failure to treat according
to guidelines runs the risk of patients requiring expensive emergency
treatments repeated many times, which is not cost saving.
12. The immigration status of migrants is
the responsibility of the Home Office. HIV status should not be
a sole factor in deciding immigration status of individuals, nor
should the need for antiretroviral treatment ensure granting right
of residency.
PROGRESS TO
DATE IN
IMPLEMENTING THE
RECOMMENDATIONS OF
THE COMMITTEE'S
INQUIRY INTO
SEXUAL HEALTH
(THE COMMITTEE'S
THIRD REPORT
OF SESSION
2002-03)
Summary
The Committee's report raised the profile of
sexual health and made this a higher priority. The result of increased
resources has had some impact on GUM service delivery. However,
there are major concerns from GUM physicians with the continuing
deterioration of service access that has marked regional variation.
There is increased demand, rising STI and HIV rates with insufficient
capacity within GUM to deal with the demand. There is little capacity
across other providers who require training and support to deliver
sexual health care. Further resources are needed without delay,
which must reach the services for which they are intended. This
requires either ring fencing or robust performance management.
"Choosing Health" is welcomed but the implementation
plan and resource distribution are key to alleviating the deterioration
in GUM services since the publication of Health Select Committee
Report. Manpower, estates and space requirements are immediate
priorities for all clinics. Provision of training budgets is necessary
to build capacity amongst the plurality of sexual health providers.
Introduction
1. The National Sexual Health and HIV Strategy
published in 2001 set out a framework for improvement of sexual
health services. GUM services were identified as key stakeholders
as major service providers for sexually transmitted infection
(STI) and HIV diagnosis, treatment and care across a range of
providers. GUM services are central to clinical governance.
2. The House of Commons Health Committee
Sexual Health Report published in 2003 was crucial to raising
the profile of sexual health and getting this onto the political
agenda where professional and voluntary care organisations had
failed to get their concerns acted upon. The resultant increase
in resource was welcomed but the £8 million recurrent resource
received by GUM services was less than a third of the £22-30
million estimated in 2001 to address capacity issues. This lack
of recurrent resource has been a major factor in continuing deterioration
of services.
3. The recent publication of the White Paper—"Choosing
Health: Making Healthy Choices Easier" has started to address
many of the issues raised by the committee. Sexual health has
been recognised as a major public health problem. There is now
political leadership with central direction. The £130 million
allocated to "modernisation of genitourinary medicine services"
would impact on service.
4. Concerns persist that BASHH wishes to
draw to the Health Select Committee attention.
Recent Epidemiological data (Ref 1)
5. The numbers of newly diagnosed HIV accelerate
year on year. There are an estimated 53,000 cases of HIV (HPA
data 2003). Between 2001-02 and 2002-03 there was a 20% and 19%
increase respectively of reported new cases. Of the 7,000 new
cases in 2003 over half were infected abroad from high prevalence
areas. This increases the burden on services disproportionately
as these patients are often complex cases, presenting late with
many other social and health care needs.
6. Co-infection with other sexually transmitted
infection is increasingly common. Hepatitis C in HIV positive
patients is an additional burden requiring more complex management
and expensive medication
7. Since the publication of the National
Sexual Health and HIV Strategy in 2001, overall STI diagnoses
have risen by 11% (Table 1). There is geographical variation,
with the Northern and Eastern regions showing the most marked
increases.
(a) Syphilis outbreaks have continued with
an increase of 112%. The epidemic now affects heterosexuals in
addition to men having sex with men (MSM). Cases of congenital
syphilis are being seen. However, there is no national surveillance
system for congenital syphilis at present.
(b) Gonorrhoea cases diagnosed in GUM clinics
have increased by 5% from 2001. Whilst between 2002-03 there was
an apparent reduction in gonorrhoea of -2% through GUM surveillance,
laboratory reports increased by 11%. From 2002-03, there was an
increase of 11% of gonorrhoea in MSM indicating continuing high-risk
behaviour in this group.
(c) Diagnosed cases of Chlamydia have increased
by 25% from 2001-03. This may in part be due to Chlamydia screening
activity in other settings generating higher levels of awareness
within the young sexually active population and more coming forward
for testing.
GUM response to National Sexual Health and HIV
Strategy
8. All clinics have changed their clinical
practice and protocols to increase capacity since the publication
of the national strategy. With increased resource of 8% over the
baseline cost for GUM Clinics of about £114 million, workload
figures increased by at least 15% in 2003.
9. Virtually all now offer HIV testing to
all new patients and almost half have moved to an opt-out policy
for testing. The targets set in the Sexual Health and HIV Strategy
to reduce undiagnosed HIV have been surpassed. Tests offered to
MSM are now more than 64% (2007 target 60%). For heterosexual
attenders the offer rate is over 56% (2004 target 40%).
10. The proportion leaving the clinic with
an undiagnosed HIV infection has fallen from 55% to 45% for MSM
and for heterosexuals from 48% to 41% between 1998 and 2003.
11. For Hepatitis B vaccination, 85% received
the first dose (2004 Target of first dose uptake of 80% in 2004).
Access to GUM services
12. The ability for patients to be seen
has deteriorated since 2001 with the increased demands of patients
wishing to access the services. In 2001 the mean waiting time
was 11 days for men and 12 days for women.
13. The joint BASHH/HPA monitoring of access
in May 2004 showed that overall in England only 38% of patients
were seen within 48 hours and 30% wait more than two weeks to
get an appointment.
14. There is regional variation with worst
access outside London. In Northern region 50% of the patients
wait more than two weeks to be seen with only 21% seen within
48 hours; in Yorkshire and Humberside and Eastern 45% have to
wait over two weeks with only 28% able to access a service within
48 hours.
15. The regional data for GUM waiting times
for clinics compared with the number of cases diagnosed show increasing
diagnoses of Chlamydia, gonorrhoea and syphilis in association
with increased waiting times. (Table 2). These data do not necessary
prove a causal link but the argument that increased delay to diagnosis
and treatment provides greater opportunity for onward transmission
of infection is compelling.
Allocation of resources
16. Although sexual health services were
deemed a priority, with "Shifting the balance of power"
the lack of a star rating for STIs and HIV within Performance
and Planning frameworks 2001-04 resulted in inability to ensure
investment in sexual health.
17. The 2004 DH figure for investment and
modernising in GUM services is £26 million; In January 2003,
90% of £5 million allocated direct to GUM clinics was received.
£10 million was allocated as recurrent funding in 2003-04
of which £8 million was distributed to PCTs by July 2003.
Only 64% received their full allocation clinics. Of a further
£5 million of non-recurrent money given for GUM services
in January 2004, approximately 50% of the money reached its intended
destination.
18. BASHH has received further reports that
some Trusts who agree to carry over the money to 2004-05 have
used money for more pressing priorities. One example serves to
illustrate the difficulties faced by front line clinicians. A
GUM consultant negotiated that £58,000 was carried over from
2003-04 to 2004-05. Job descriptions were ready, an advertisement
placed when she was informed by her immediate manager that this
money was no longer available. It was required for an overspend
elsewhere. She raised this with the PCT Sexual Health Commissioner,
Strategic Health Authority Public Health Lead having failed to
influence the Chief Executive. She has been told to keep quiet
and stop making a fuss. This bullying behaviour is unjustifiable.
19. £1.1 million was released in 2004-05
to the 10 successful pilot sites identified through the Joint
DH/BASHH Working Group. This is short of £2 million promised
for 2003-04.
Current Issues
Demand for GUM services is not being met. Manpower
and space are major issues.
20. The Health Select Committee was informed
of a shortfall of 90% in consultant numbers against the recommendations
of the Royal College of Physicians (paragraph 8, page 95). Consultant
numbers have increased by 4% between 2002-03. Nearly 16% consultants
still work single-handedly compared with 19% in 2002.
21. Increased numbers of nurses, health
advisers and laboratory technicians are needed to cope with demand.
22. The poor condition of many GUM premises
was noted by the Health Select Committee (recommendation 14).
Around 40% clinics do not have dedicated premises.
23. More than eight out of 10 clinics regard
shortage of space to be a major limiting factor inhibiting service
development and modernisation
24. The DH/BASHH Group reviewed more than
70 tenders amounting to £100 million. £15 million of
capital monies provided in 2003 have now been allocated but mainly
to those in unsafe accommodation and portakabins. This capital
money is welcome but is insufficient to address the sub-standard
accommodation resulting from years of under-investment.
25. Information campaigns although targeted
to change sexual behaviour, inevitably raise awareness around
STI which fuels demand for services especially those emphasizing
asymptomatic nature of many infections
26. Delaying health information campaigns
until more capacity exists would avoid difficulties in meeting
public expectations.
Chlamydia Screening
27. The goal of national coverage for Chlamydia
screening by March 2007 indicated in "Choosing Health"
is welcomed.
28. Almost half of all GUM clinics still
do not have Nat's Chlamydia testing available for all men and
women attending as patients.
29. There should be equity of access to
NAATs irrespective of age. In practice there is a postcode lottery.
For example an area which has financial support for Chlamydia
screening programme has NAATs for under-25s presenting in community
and other screening settings whereas the GUM Department has EIAs.
30. In 2004, 45% of laboratories are still
using EIA test methodology and 45% of all Chlamydia tests are
undertaken using EIA. The £7 million allocated to change
test methodology will not impact until the financial year 2005-06.
Costs of HIV treatment and care
31. Increase in detection of new HIV cases
means an increase of costs of HIV antiretroviral therapy The cost
of provision for newly diagnosed patients in 2003 will be in the
region of £35-50 million (50-70% of 7000 needing treatment
at £10,000 per year)
32. The laudable aim of reducing undetected
HIV infection will increase the number of people requiring HIV
treatment and care. Overspend on drug budgets this year is inevitable
in London. It is unlikely that the financial impact has been fully
appreciated or can be catered for by PCTs across England.
Training and Clinical Governance
33. There is little capacity outside GUM
services at present. It will take time for capacity to build up
amongst the plurality of sexual health providers.
34. Training programmes supported by GUM
are required. There is no training budget allocation for this.
Whilst GUM physicians are committed to provide theoretical training
through the STI infection foundation course devised by BASHH in
collaboration with other providers, providing practical training
will require additional funding over that required for increasing
service capacity.
35. The speciality recognises its key role
in clinical governance of sexual health service provision to ensure
standards are maintained across service providers and quality
of care for patients through clinical networks. Time is needed
to fulfil these roles and to increase collaboration between the
statutory and voluntary care sector to better utilise resource.
Implementation of "Choosing Health"
36. BASHH welcomes the public health white
paper and looks forward to supporting its implementation
37. The resource allocation and distribution
of £130 million for modernising GUM services is key to achieving
the 48-hour access goal. Delay until 2006-07 will give little
chance of success. There is some concern that this money is unlikely
to be sufficient to cover both recurrent resources and the capital
expenditure needed to modernise clinics to be fit for the 21st
Century.
38. Robust performance monitoring by Strategic
Health Authorities is clearly a requirement to ensure that resources
directed to PCTs reach the services for which they are intended.
Conclusion
39. An increase in GUM service capacity
is essential. This requires increase in manpower, space and improvement
of facilities
40. This needs immediate action with no
delay in provision of some resource to incrementally move towards
the 48-hour access target. This should be clearly defined as a
target for "next available appointment" and not emergency
walk in.
41. Community provision requires incentives
to engage primary care. Specific Quality and Outcome Framework
points are needed within the nGMS GP contract to achieve this.
42. GUM services have a responsibility to
facilitate training and support other health care workers who
will be expected to provide STI diagnosis and care. GUM services
need a training budget need to increase their training capacity.
It is important that PCTs recognise the key role of GUM in terms
of Clinical Governance. Training and responsibilities for diagnosis
and management of STIs and HIV should be overseen by those who
are accredited in the speciality of GUM/HIV.
REFERENCES
1. HPA—Annual Report 2004 "Focus
on Prevention".
2. Kinghorn GR, Abbott M, Robinson AJ, Ahmed-Jushuf.
BASHH survey of additional Genitourinary medicine-targeted allocations
in 2003 and 2004. Int J STD AIDS. 2004 Oct 15: 650-2.
Table 1
STI DIAGNOSES IN ENGLAND 1995-2003
| Number | of annual
| cases | | % increase
| |
| | |
| | | |
| 1995 | 2001
| 2003 | | 1995-2003
| 2001-03 |
| All STI diagnoses | 428,575 |
608,636 | 674,827 | 1.574583
| 57% | 11% |
| Syphilis | 102 | 717
| 1,519 | 14.89216 | 1,389%
| 112% |
| Chlamydia | 29,241 | 68,256
| 85,550 | 2.925687 | 193%
| 25% |
| Gonorrhoea | 9,950 | 22,418
| 23,584 | 2.370251 | 137%
| 5% |
| Genital warts | 51,236 | 62,551
| 65,414 | 1.276719 | 28%
| 5% |
| Genital Herpes | 15,021 | 17,076
| 17,173 | 1.143266 | 14%
| 1% |
| 
