Select Committee on Health Written Evidence


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
Numberof annual cases % increase
19952001 20031995-2003 2001-03
All STI diagnoses428,575 608,636674,8271.574583 57%11%
Syphilis102717 1,51914.892161,389% 112%
Chlamydia29,24168,256 85,5502.925687193% 25%
Gonorrhoea9,95022,418 23,5842.370251137% 5%
Genital warts51,23662,551 65,4141.27671928% 5%
Genital Herpes15,02117,076 17,1731.14326614% 1%




 
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