Select Committee on Health Written Evidence


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 services.

  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 6,606—more than twice the number in 1998 (1).

    —  Non-HIV Sexually Transmitted Infections continue to rise overall—Chlamydia 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 our evidence.

  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 prognosis—the 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) show:

    "It is encouraging that condom use has gone up but probably not enough to offset the increase in sexual partners" (10).

    "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 contract.

  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 practice.

  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 study—but 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 addressing—there 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 encouraged.

  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 Health—health 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 study—three years on J of STD and AIDS 2004 15 744-746.

(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 Study B9D 2002 conference.

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