Select Committee on Health Written Evidence


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.


  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.


  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.


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.


  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£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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