Memorandum by Dr Mayura Nathan (HA 30)
1. This memorandum is written by Dr Mayura
Nathan, in his capacity as Lead GUM Physician at the Homerton
University Hospital Foundation Trust in Hackney (East London)
and as the Chairman of the North East Sector (London) GUM (Sexual
Health) Group. I have been working in the field of Sexual Health
and HIV for over 20 years. This memorandum reflects the changes
perceived locally and sector-wide in the last two years.
2. A Service Network has been established
in North East London for HIV and Sexual Health, to enable improved
standards of care and service provision. The GUM Group has recently
met and identified priorities for the network.
3. Some improvement has been noted in patient
access to Sexual Health Services since the recent injection of
one off monies and revenue funding to GUM services by the Department
of Health. There remains however, examples of two week wait for
an appointment to a GUM service as well as people turning up to
open access services and being turned away due to capacity problems.
While the involvement of General practices in the provision sexual
health is welcome and will improve accessibility to a wider public,
it is felt that this will not solve the problems of capacity and
access to people seeking GUM services.
4. Department of Health has recently commissioned
the proposal of a National Standards for Sexual Health Services.
It is felt that setting standards will enable a more equitable
service provision across the UK. While issues relating to access,
care standards and referral pathways and some prevention work
could be addressed through national standards, it will not address
other issues facing sexual health services such as burden of disease
or local variation in disease spread. In 2004, we identified an
outbreak of infectious syphilis amongst commercial sex workers
in Hackney. The capacity problems do not allow a robust diversion
of resources to study the outbreak in detail.
5. Service network arrangements are likely
to help with access to full range of sexual health services, through
care pathways and explicit referral arrangements. There are limits
however, in terms of distance people are willing to travel or
prepared to wait for specialist services. Locally some specialist
services have a waiting time of five to six months and this may
have an impact on the disease complexity.
6. Service networks should help ensure collection
of unified data from services and thus make better comparison
of disease pattern and management. However, the type of data collection
in general practices or family planning clinics is different to
the data collected by GUM services. The use of READ codes by general
practices and KC60 codes by GUM services will make it difficult
to pool the data, to help ensure common standards.
7. The setting up of a two year programme
of GUM Clinic Review is welcome and timely. However, unlike some
past initiatives, we need to make sure sufficient monies follow
recommendations by the review bodies. Capital allocation and space
has been a continued problem in many GUM services including those
in North East London.
8. Many sexually transmitted diseases show
an upward trend in numbers affected in the last few years. Behavioral
change in populations, for example, adopting safer sexual practices,
are slower to evolve than one would like, and therefore a realistic
approach to dealing with disease burden is needed.
9. We recommend that a thorough review of
GUM clinic premises and services are undertaken and standards
are laid down based on activity both current and future projected
levels. In our local example, we opened new clinic premises in
1998 based on attendance figures of 1996 (12,000 patient visits).
The anticipated attendance level was 17,000 per annum. Currently
we are seeing 26,000 attendances with some being turned away.
We allowed for 75 HIV patients to attend for care in 1998. Our
HIV patient population currently stands at 450.
10. We recommend that no patient/client
motivated to attend a service should be turned away and that sufficient
capacity should be available based on demand.
11. We recommend that sufficient flexibility
in services should be available to deal with outbreaks or variable
demand. At the least, some pooled resources sector-wide should
be available to respond swiftly to increased demand in individual
In conclusion, it is my opinion, that several
good initiatives are being planned to improve access and care
for people seeking sexual health services, but we need to ensure
that sufficient resources are targeted to enable the implementation
of the recommendations. We also need to respond to higher demands
that are placed in some parts of the country.
Memorandum by the Royal College of General
Practitioners (HA 31)
1. The College welcomes the opportunity
to submit written evidence to the Inquiry by the Health Committee
into new developments in HIV/AIDS and sexual health policy.
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education; training; research;
and clinical standards. Founded in 1952, the RCGP has over 22,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
3. The context of the debate about sexual
health policy includes the following information which notes the
worsening of the sexual health crisis since the Health Committee
reported on 11 June 2003:
In 2003, the total number of new
HIV diagnosis was 6,606more than twice the number in 1998
Non-HIV Sexually Transmitted Infections
continue to rise overallChlamydia is now the commonest
STI diagnosed in England, Wales and NI having risen by 8% from
82,558 to 89,431 from 2002 to 2003 while Syphilis is also of particular
concern because of the rate of increase (28% in men, 32% in women)
from 2002-03 (2).
The overall conception rates for
under 16s have remained at much the same level since 1975 and
the latest figures show a small rise in conceptions in under-18s
in England and Wales from 42.7 to 42.8 per 1,000 (3).
In 2003, for women resident in England
and Wales, the total number of abortions was 181,600, compared
with 175,900 in 2002, (a rise of 3.2% and the highest ever annual
total) and the under-16 abortion rate was 3.9 compared with 3.7
in 2002 (4).
4. The concept of charging overseas patients
for medical care services raises a number of difficult and complex
issues. The College discussed these in its response to the Department
of Health consultation of May to July 2004 which set out proposals
to exclude overseas visitors from free NHS Primary Medical Services.
A copy of the College's response is attached and forms part of
5. The key issues for us about the proposed
changes in charges as far as they affect overseas patients seeking
access to HIV/AIDS services are:
This is a public health issue of
protecting the population at large as well as the effect on particular
individuals and the additional barrier of cost should not be put
in the way of mitigating the spread of HIV/AIDS among the general
public: we note that the Health Protection Agency singles out
"the migration of people from areas of the world where there
is a high prevalence of HIV, such as sub-Saharan Africa"
as a major factor in the increase in heterosexual spread of HIV
in the UK (5).
General Practitioners and their staff
should not be required to police patients between those eligible
for free access to HIV/AIDS services and those not.
We currently see HIV Positive patients
being denied treatment when they are well. When a crisis point
is reached, these patients are then admitted to Accident and Emergency
departments with AIDS defining conditions only partially to recover,
be discharged in remission and then be denied anti-retrovirals
again and then be readmitted.
The College would like to see greater
encouragement for HIV testing to allow for earlier diagnosis and
provide better prognosisthe proposed changes will only
discourage patients to test for their HIV status.
6. The College greatly welcomes the emphasis
on sexual health and HIV in the Government's health agenda. We
wish to bring to the Committee's attention the fact that general
practice continues to be a major provider of sexual health services.
For example, 80% of contraception is provided in primary care
(Source: ONS 2003); and general practice has unmatched accessibility
and geographical coverage (Source: Audit Commission 2002).
7. Though the Committee Report helpfully
identifies the primary causes of the deterioration in sexual health,
it is to be regretted that it gives no consideration as to how
these primary factors may be modified. This omission has to be
addressed if progress is to be made. This has now been widely
acknowledged as the following (and many other references 6-9)
"It is encouraging that condom use has gone
up but probably not enough to offset the increase in sexual partners"
"The past decade has seen substantial increases
in high-risk sexual behaviours in the British population. Although
condom use has also increased, this is likely to have been offset
by greater increases in unsafe-sex" (11).
8. While the Report also states that the
Committee sees "no benefit in preventative approaches based
primarily around promoting abstinence", evidence of the effectiveness
of an abstinence component continues to grow in places as diverse
as Uganda (12) and the USA (13). As teen birth rates are now at
their lowest level in the USA since 1946 (14) and the under 19s
abortion rate in the USA is now lower than in the UK, perhaps
it is time to reconsider the dismissal of abstinence in the light
of these facts.
9. We set out below specific comments relating
to the issues and recommendations of the Committee's Third Report
of Session 2002-03. In essence, though, the areas that need to
be addressed are to obtain some quality and performance markers
regarding sexual health into the General Medical Services contract
and to place a greater emphasis on educating and training about
sexual health and HIV matters.
10. The Committee's Report recommendations
in relation to primary care have not been enabled by the new GMS
11. The contract has not addressed the holistic
nature of the National Strategy for Sexual Heath & HIV, it
continues to separate the basic elements of sexual health (eg
contraception, cervical cytology and STIs).
12. There are no quality or performance
markers for sexual health in essential services to act as a driver
for increased quality or awareness of sexual health in general
13. The Committee's Report recommendations
in relation to general practice have not been addressed in GPs'
contractual arrangements or provision of training.
14. GPs are also aware that there are too
many referrals to secondary care which leads to long waiting lists
for those with transmitable diseases. Communication between primary
and secondary care could be better so it may be helpful, in moving
treatment for patients forward, if general practices were empowered
to deal with the most basic elements of STD management. If such
empowerment were granted, an educational programme (similar to
that which enabled GPs to manage drug users) should be provided
as a matter of urgency.
15. Recommendation 15 (re chlamydia screening
in general practice) is not facilitated by the contract nor to
date by the National Chlamydia Screening Programme which has been
delayed by a recommendation to await the results of a reinfection
studybut there now exists enough published (15, 16) and
unpublished (17) evidence to know more about reinfection rates.
The interval for repeat screening in those who remain at risk
should be no longer than a year and a shorter interval may be
more appropriate. It is time to roll out Chlamydia screening to
the vast majority of under 25s, as this will be the only way to
have an impact given its prevalence and ease of transmission.
GP practices would be successful in delivering this service if
it is incentivised.
16. Recommendation 22 (re diagnosis and
care of HIV) is not supported by the contract at the essential
level and very few GPs or PCTs provide or commission enhanced
services. Other issues here also need to be addressed such as
recognising that HIV/AIDS is a specialist area of health care
which requires a multidisciplinary team; and that many HIV/AIDS
patients (at least those picked up in obstetric services) are
first generation immigrants or asylum seekers with language needs.
17. Recommendation 28 (re potential of primary
care as a sexual health service provider and need for training)
needs addressingthere are no incentives in essential services.
18. Recommendation 30 (re quality of service
from GP & training) also suffers from a lack of incentives
and should be recognised as specialised enhanced services.
19. Recommendation 32 ("Improving access
to contraception services leading to reduction in abortion rates")
ignores the positive choice by some women of using abortion as
contraception, or a planned pregnancy with change of circumstances.
This Recommendation needs to go hand in hand with measures to
improve life choices and in dealing with peer pressure regarding
sexual health. There are many grass roots "say no" campaigns
which need support and integration with health providers. There
is provision for free condoms in GP surgeries but there is the
question of dispensing repeats. Whatever is appropriate to the
needs of particular communities should be supported, with innovative
ideas to tackle the health issues in different locations being
20. Recommendation 34: there has been an
increase in consultations for male libido and erectile dysfunction
(ED) problems in the last three years; most treatments for ED
do not qualify for NHS prescriptions. The cost shift as outlined
in savings on treatment for depression, fertility and marital
breakdown should be reflected in a shift in the prescribing budgets
to allow treatment for male libido and erectile dysfunction problems
within NHS budgets; the suggested results of male sexual dysfunction
may not be seen or may be difficult to cost, and are therefore
easier to ignore.
21. The sexual health secondary care services
are under funded; GPs are under resourced, staffed and trained
to be able to suddenly take on this work from secondary care,
particularly when dealing currently with the demands of nGMS.
22. A GPwSI with skill and interest in these
areas, with separate commissioning of the work with appropriate
support staff, would be one way to deal with this; however, PCTs
are reluctant to commission enhanced work even that which is already
outlined in the contract let alone work outside of it.
23. Recommendation 50: The plan is for access
to a Genito-Urinary Medicine unit or specialist family planning
within 48 hours by June 2005; currently this is typically two
weeks for the GUM and one week for the specialist sexual health
clinics in the area. But target setting does not take account
of the fact that people cannot be forced to attend to follow or
complete treatment. Any policing of targets with penalties will
further reduce available services; as an alternative, perhaps
strategies and good practice could be identified and encouraged
to be rolled out and resourced effectively these areas.
(6) Wilson D. Partner reduction and the prevention
of HIV/AIDS BMJ 2004 328 848-9.
(7) Shelton J D, Halperin D T, Nantulya Vinand et
al. Partner reduction is crucial for balanced "ABC"
approach to HIV prevention BMJ 2004 328 891-3.
(8) Genuis S J Genuis S K. Adolescent behaviour
should be a priority BMJ 2004 328 894.
(9) Halperin D et al The time has come for
common ground on preventing sexual transmission of HIV Lancet
2004 364 1913-4.
(10) Adler M Sexual Healthhealth of the Nation
Sex Trans Infect 2003 79 84-85.
(12) Stoneburner R L Low-Beer D. Population-level
HIV declines and behavioural risk avoidance in Uganda Science
2004 304 714-8.
(13) Mohn J K Tingle L R Finger R. An analysis of
the causes of the decline in non-marital birth and pregnancy rates
for teens from 1991-95 Adoles and Fam Health 2003 3 39-47.
(14) Birth rate among young US teenagers is lowest
in years. Anon BMJ 2004 329 1254.
(15) V F Lee; J M Tobin; V Harindra. Re-infection
of Chlamydia trachomatis in patients presenting to the
genitourinary medicine clinic in Portsmouth: the chlamydia screening
pilot studythree years on J of STD and AIDS 2004
(16) Warner L, Newman D R Austin H D et al.
Condom effectiveness for reducing transmission of gonorrhea and
chlamydia: the importance of assessing partner infection status
Am J Epid 2004 159 242-51.
(17) G Paz-Bailey1, E Koumans1, A Pierce et al.
Condom Protection Against STD: a Study Among Adolescents Attending
a Primary Care Clinic In Atlanta at http://www.stdconference.org/
Study B9D 2002 conference.