APPENDIX 26
Memorandum by the BMA (HA 33)
The British Medical Association has called on
the Government to tackle the current sexual health crisis, reduce
the soaring rates of sexually transmitted infections and address
the humanitarian and public health consequences of the proposed
changes in the charges for overseas patients. The BMA therefore
welcomes the Health Select Committee's inquiry into new developments
in HIV/AIDS and sexual health policy.
The BMA shares the Committee's concerns, contained
in its report on Sexual Health in June 2003, which concluded that
the service was in "a state of crisis". The BMA was
encouraged to see that the report recommended more resources,
including doctors, for sexually transmitted infection (STI) prevention
and treatment.
The BMA is particularly concerned that the increasing
incidence of STIs is leaving genito-urinary medicine (GUM) clinics
unable to cope. The workload of GUM clinics increased by around
50% between 2002 and 2003. Many patients are not being seen within
the 48-hour target but have access to the service only after weeks
of delay.
THE CONSEQUENCES
OF THE
NEW AND
PROPOSED CHANGES
IN THE
CHARGES FOR
OVERSEAS PATIENTS
WITH REGARD
TO HIV/AIDS
SERVICES
In its response to the consultations on the
proposed changes to eligibility for both primary and secondary
care, the BMA expressed concern about both the humanitarian and
public health consequences of the changes, particularly in relation
to failed asylum seekers. The difficulties faced by this particularly
vulnerable group were also outlined in the BMA's 2002 report,
Asylum seekers: meeting their healthcare needs.
The BMA's main area of difficulty concerns refusal
of free ongoing HIV care to people who are in the country without
proper authority. In theory, if public health and humanitarian
concerns are put aside, there is an obvious argument for excluding
from treatment people who have not obtained proper permission
to be in the UK. In practice, however, this is likely to mean
that some people who are already impoverished and on the margins
of society are abandoned when effective treatments are available
to help them. Doctors' ethical training is based on the notion
of an ethical duty to respond to "need". It is also
in society's interests to ensure that treatable diseases, especially
those that are transmissible, are not ignored since ultimately
this could be a problem for the wider society.
Therefore in correspondence with ministers,
the BMA has previously expressed concern about exclusion of this
group of patients:
— on humanitarian grounds in that health
professionals should not be obliged to refuse care to patients
in need because they cannot pay;
— the fact that the entitlement regulations
are complex means that it is difficult for health professionals
to assess precisely who is entitled to free care and it should
not be part of their job to do so; and
— on public health grounds if patients
with transmissible infections are refused appropriate treatment.
Doctors in some parts of the country are already
expressing concern to the BMA about the withdrawal of all health
and social care support from failed asylum seekers. They are not
necessarily immediately deported and they currently have no right
of appeal, even though a judge ruled that abandonment of such
people can amount to inhumane and degrading treatment. (S,
D and T v Secretary of State for the Home Department,
[2003] EWHC 1941.) It is important to stress that late HIV infection
especially in people from overseas is likely to be associated
with other serious conditions such as TB. High viral loads in
patients with untreated HIV allow more ready sexual transmission—possibly
into the resident population.
From a public health perspective, the majority
of serious HIV-related morbidity and mortality in the UK is associated
with missed or late diagnosis, which suggests that accusations
of "health tourism" in this context are misplaced. If,
for example, people arriving into the UK from Africa with HIV
were treatment tourists, they would access treatment earlier rather
than turning up as emergencies in A&E with undiagnosed infection
as is currently the case.
Primary care is currently being encouraged by
Government to take on a bigger role in the diagnosis of HIV and,
for public and individual health reasons, this should not be discouraged.
The BMA would welcome the introduction of flexibility on this
issue. We would very much welcome the opportunity to work with
the Government in drawing up guidelines on managing this population
group in ways that reflect doctors' ethical obligations towards
vulnerable patients.
A very important part of HIV prevention, especially
for those who were infected with HIV overseas, among whom women
outnumber men, is the prevention of transmission from mother to
child. Appropriate interventions before, during and after birth
can reduce the risk of HIV transmission from mother to child from
25-35% to under 2%, but in order to achieve this, ongoing medical
care and social support is crucial. Aside from the moral and public
health arguments, there is also an economic argument for preventing
mother-to-child transmission. Fewer HIV-infected children requiring
complex monitoring and treatment for their HIV infection will
potentially mean lower costs to the NHS. The BMA would be deeply
concerned if women in the UK are denied this treatment or its
associated support as a result of their immigration status.
As an additional point, it is internationally
acknowledged that a programme of social support and medical care
for those infected helps to reduce the fear and stigma associated
with the disease, resulting in more effective prevention of new
infections.
PROGRESS TO
DATE IN
IMPLEMENTING THE
RECOMMENDATIONS OF
THE COMMITTEE'S
INQUIRY INTO
SEXUAL HEALTH
The BMA welcomed the recommendations contained
in the Health Select Committee's 2003 report on sexual health.
However, recent reports have subsequently drawn attention to the
increasing numbers of new diagnoses of sexually transmitted infections
(STIs) in the UK. Since 2002, almost all STIs have been on the
increase, with gonorrhoea, syphilis and chlamydia among the most
common.
According to the latest figures from the Health
Protection Agency (HPA):
— HIV diagnoses at 6,780 in 2003 was
more than double the 3,093 diagnoses in 1999. [41]
— In 2003 there were an estimated 53,000
people living with HIV in the UK, of whom 14,300 (27%) were undiagnosed.
[42]
— the total number of HIV-infected
patients seen for care in the UK rose by 16% from 31,861 in 2002
to 37,079 in 2003. [43]
— In 2003, genital chlamydia was the
most common diagnosis made in genito-urinary medicine (GUM) clinics
in the United Kingdom (UK). [44]
— In 2003, diagnoses of uncomplicated
gonorrhoea decreased by 4% in England, Wales and Northern Ireland.
61
— Between 2002 and 2003 diagnoses of
primary and secondary syphilis increased by 28% (1399) in men
and 32% (181) in women in England, Wales and Northern Ireland.
61
— Genital warts remain the most prevalent
viral STI diagnosed in England, Wales and Northern Ireland. 61
The recent Department of Health announcement
(26 January 2004) of a new £300 million programme over three
years to modernise sexual health services and to run an advertising
campaign is welcome and the BMA is pleased that the Secretary
of State for Health has recognised the need to act now. The £130
million to modernise GUM clinics and other STI diagnosis and treatment
providers will be needed to cope with the increased level of demand
that will result from the raised awareness of the advertising
campaign. It is important to ensure investment to increase capacity
comes early enough to respond to increased demand fostered by
the campaign. Furthermore, the BMA welcomes the £80 million
to speed up roll-out of national chlamydia screening programme.
The BMA is particularly concerned that the increasing
incidence of STIs is leaving genito-urinary medicine (GUM) clinics
unable to cope. There were 2,046,848 attendances during 2003 compared
to 968,842 attendances in 1997 (House of Commons' Hansard,
13 December 2004, col 969W). Opening times are sometimes limited
to 21 hours a week with many operating from portakabins. Access
to clinics is not fast enough, with waits of up to 12 days for
urgent cases and eight weeks for general check ups. There must
be a reduction of the current lengthy waiting times to GUM clinics.
The HPA (20 November 2004) published the first national audit
of GUM waiting times which showed that less than one third of
people are currently seen within 48 hours—the new target
for an appointment to be seen from the time of first contacting
a service. The BMA welcomes this target but is concerned about
ability to meet it.
The public health white paper Choosing Health:
making healthier choices easier (2004) uses the phrase "from
referral" in promising 48 hour access to GUM services. The
BMA is pleased to have received an assurance from the Secretary
of State for Health that "referral" in this context
should be taken to include "self-referral" and that
the Government has no intention to limit the open access nature
of GUM.
BMA RECOMMENDATIONS
Policy makers
— Policy-makers need to take note of
rising STI prevalence and its costs, against the benefits of prevention,
early diagnosis and treatment in the context of the health of
the nation.
Costs of STIs include preventable infertility,
ectopic pregnancy, hospital admissions for pelvic inflammatory
disease, and psychological distress. The risk factors for STIs
overlap with those for HIV, and some STIs facilitate the transmission
of HIV. The average lifetime treatment costs for an HIV positive
individual is calculated to be between £135,000 and £181,000,
and the monetary value of preventing a single onward transmission
is estimated to be somewhere between £500,000 and £1
million in terms of individual health benefits and treatment costs.
— Funding should be targeted at GUM
clinics which suffer chronic underinvestment.
From a survey conducted with GUM clinics, the
British Association for Sexual Health and HIV estimates that a
third of the money allocated in 2003-04 to primary care trusts
(PCTs) for GUM services did not get through to clinics and the
money was spent on alternative priorities. Such money should be
ring-fenced and monitored to ensure that it is spent on sexual
health services.
— As part of the broader strategy to
improve sexual health, Ministers should note the importance of
including sexual health in Healthcare Commission's inspection
criteria.
The proposals are currently out for consultation
and the BMA will be responding.
GUM services
— More GUM facilities that are geographically
accessible are urgently required, with longer opening hours, more
trained staff and increased funding.
Clinics are currently faced with rising rates
of STIs, a lack of resources (such as experienced personnel, adequate
space, and new funds for expanded screening) and an increase in
demand for services such as improved diagnostic testing.
— Clinics should also be encouraged
to take a more proactive role to increase their publicity and
should also be available away from city centres. Therefore the
BMA welcomes government proposals for more community-based STI
services.
Young people
— There should be proper investment
in sexual health service provision that young people feel comfortable
using. This would reduce the burgeoning levels of STIs.
— School education strategies that
increase students' knowledge of the full spectrum of STIs are
essential and should be a core part of the National Curriculum.
Education strategies also develop young people's
skills such as negotiating in relationships and accessing/using
sexual health services. Well designed sex education programmes
have been shown to be effective and education tailored for adolescents,
which supports and promotes healthy behaviour and attitudes regarding
sexual healthcare, remains an essential part of schooling.
— Sexual health services should be
available to all young people and should be accessible (in terms
of opening hours and location) to those still in full time education.
The BMA publication, Consent, rights and choices
in health care for children and young people offers comprehensive
practical guidance on the ethical and legal issues which arise
in the healthcare of patients under 16 years of age. More young
people's clinics are needed and it is also important that school-based
professionals (including school nurses) are able and willing to
refer young people to GUM clinics as well as providing some aspects
of sexual healthcare themselves.
— As well as their key role in preventing
unintended pregnancies, community family planning clinics have
a key role to play in the prevention of STIs and should target
their services directly at adolescents via accessible, drop-in
services.
Health professionals
— General practitioners and other health
professionals working in the field of sexual health should receive
more training about the diagnosis and management of STIs.
There is a lack of commissioning of sexual health
services by PCTs despite practices being willing and able to carry
out this work. The new general medical services contract highlights
sexual health as enhanced service.
— All healthcare professionals dealing
with sexual health must be non-judgemental, able to reassure individuals
and to maintain confidentiality.
Healthcare providers should maintain their knowledge
of the most recent information relating to STIs, their prevention
and control, and provide appropriate medical management for an
illness.
— There should be improved training
for primary care staff in discussing sexual histories and counselling.
When appropriate, general practitioners should
refer patients to GUM clinics, where staff have the expertise
to assist in partner notification, education and counselling.
GUM services can also play an important role providing training
and working in partnership with primary care on these aspects
of care. Adopting proactive healthcare behaviour in both the prevention
and early detection of STIs is essential. Early diagnosis will
prevent long-term health implications posed by STIs.
— The provision of risk-reduction counselling
(such as guidelines on safer sex, routes of transmission) should
be a standard part of STI clinical care.
It is essential that anyone involved in sexual
health has the training to be able to both thoroughly understand
modes of transmission and guidelines for safer sex, and feel comfortable
discussing sex and sexuality. This is more difficult when sexually
transmitted infections are not the clinician's main responsibility.
Training may therefore be required to overcome potentially counter-productive
embarrassment or unease among healthcare workers.
— With the current move towards a greater
plurality of service providers for STI diagnosis and treatment,
strengthening and prioritising partner notification is an important
measure in preventing the spread of STIs.
It should involve careful history taking to identify
all potentially infected partners, and requires better support
services for those who have to inform a partner(s) as this can
be daunting. This should include advice on who to notify, and
follow-up to ensure adherence to treatment. Partner notification
is a particular area where close collaboration between sexual
health specialists and primary care is urgently needed.
FURTHER RECOMMENDATIONS
Based on the evolving HIV and STI epidemics,
policy-makers and others should also give urgent consideration
to:
— Reviewing and strengthening primary
prevention efforts directed at homo/bisexual men.
— Offering and recommending annual
HIV testing to homo/bisexual men attending GUM clinics.
— Promoting further voluntary confidential
HIV testing of migrants from sub-Saharan Africa in settings other
than GUM clinics where migrants may present for healthcare, for
example in general practice.
— Developing further studies of the
sexual behaviour within the UK of migrants from sub-Saharan Africa
and HIV positive individuals in order to better inform primary
and secondary prevention efforts.
— As the numbers of HIV infections
due to heterosexual transmission within the UK rises, surveillance
resources devoted to risk factor follow-up of newly diagnosed
HIV-infected heterosexuals should increase to ensure there is
no loss of timeliness in monitoring this evolving situation.
— Extending routine screening for infectious
syphilis to sexually active HIV positive homo/bisexual men attending
all centres providing treatment and care. Research is also needed
to determine the impact of syphilis outbreaks on HIV transmission
amongst homo/bisexual men.
— In view of increases in gonococcal
antimicrobial resistance, reviewing and disseminating updated
national guidelines for the treatment of gonococcal infections
which should encourage regular local audit of therapeutic efficacy.
41 www.hpa.org.uk/cdr/pages/hiv_STIs.htm£quarterly_SEP04. Back
42
HPA annual report 2003. Back
43
HPA HIV/STI annual reports 2002 and 2003. Back
44
The UK Collaborative Group for HIV and STI Surveillance. Focus
on Prevention. HIV and other Sexually Transmitted Infections in
the United Kingdom in 2003. London : Health Protection Agency
Centre for Infections. November 2004. Back
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