Examination of Witnesses (Questions 1-19)
PROFESSOR GEORGE
KINGHORN, MS
ANNE WEYMAN
AND DR
WILLIAM FORD-YOUNG
27 JANUARY 2005
Q1 Chairman: Good morning, and may I
welcome our witnesses. We are pleased to see at least two of you
before the Committee once again. As you know, this part of this
morning's session particularly is, in a sense, an update on developments
since the publication of our report on sexual health two years
ago. Obviously we are aware of a number of developments. I think
you appreciate that we are taking evidence later this morning
on one aspect of an area that we looked at during our inquiry.
I wonder if we could start by particularly asking you, Professor
Kinghorn, for your views on developments since 2002, trends on
STIs, on HIV, since we reported and what has been happening, in
your view, with regard to how quickly people can be seen at genito-urinary
clinics. As you know, we expressed a very serious concern over
the delays in people accessing treatment in various parts of the
country.
Professor Kinghorn: We are delighted
that the public health importance of STIs has been recognised,
that they have been given additional priority and that there are
new resources to support service expansion and meet patient demand
for services. We are especially pleased that the recommendations
of this Committee have been acknowledged in this way. We are very
grateful for your influence and support. In talking about the
changes that have occurred over the last two or three years, generally
there have been accelerated pressures on clinic services. In my
own city of Sheffield, our new patient episodes of care have increased
by 30%. We have had a doubling of diseases such as gonorrhoea
and syphilis and our number of new cases of HIV on an annual basis
has trebled.
Q2 Chairman: Before you go further, could
I ask you for your thinking on the reasons why more people are
coming forward. You say that there is more incidence, or is it
that people are more aware of the means of accessing help? Are
there other factors that may have a bearing on the increased presentation
of people at your clinic?
Professor Kinghorn: I think there
is very definitely a worsening, an increase, in the incidence
of sexually transmitted diseases, as evidenced by the cases of
gonorrhoea and syphilis that we are seeing. These are new problems.
Although some additional resources have gone into clinics, the
amount of resource that went in was less than that recommended
when we met with you previously. There is a widening gap between
the patient demand and our clinic capacity and, sadly, I think
that is going to get worse. It is true that there is increased
knowledge about the risk of sexually transmitted diseases, and
I am glad to see that more people are attending for check-ups
to assure themselves that they are healthy before they change
partners, but all of that just tends to increase the pressures
on services. Unless we do something to increase capacity, both
in the clinics and in other community settings, then I think that
gap is going to stay wide.
Q3 Chairman: You recall that one of the
issues we raised was this question of a 48-hour access target,
which is picked up, of course, with the White Paper. In listening
to what you have just described are the problems now, what is
going to need to be done to increase capacity to meet the target
that the Government has set?
Professor Kinghorn: I think the
target is welcome but it is very challenging for us to achieve
by 2008. Despite extensive modernisation of our clinical practice
to increase the throughput of new patients, as I have indicated,
there is still this very wide gap between capacity and demand.
In order to achieve the 48-hour target, there is a need for resource
to increase the clinic capacity not only to meet the current gap
but also the additional workload that will inevitably result from
an education campaign. We also need to increase capacity in community
settings. There needs to be additional provision of services within
community contraception clinics, also in primary care, and it
is essential that there should be increased training opportunities
for practitioners in those settings. I think that this will require
a separate training budget to be established. In the specialist
services, we do have an additional problem of space. I could employ
the people but I need to provide additional services, but I would
have great difficulty in providing the space for them to work
in the most effective way. So I hope that the current national
review of GUM services will help us to show where those resources
need to be put so that we can increase space to maximise service
capacity.
Q4 Chairman: Your comments obviously
relate to your experience in Sheffield. Do you feel that the picture
you have given us applies across the country as well as just in
your part of the world?
Professor Kinghorn: Yes, I think
the evidence is that there is a problem throughout England, but
we do know that when we look at trends in sexually transmitted
infections, there are worse problems in north and eastern England
than perhaps there are in London, but it does tend to appear that
the worst problem, in terms of increased incidence of disease,
occurs in those locations where clinic access is worse. So poor
access tends to lead to more problems.
Q5 Chairman: Is this anecdotal or can
you give hard circumstances?
Professor Kinghorn: There is evidence.
Q6 Chairman: Can you point us in that
direction?
Professor Kinghorn: There is published
evidence from the Health Protection Agency both in terms of their
GUM waiting times survey report and also in their annual reports
of STI incident that cover 2001-03.
Q7 Chairman: What you are saying is that
if there are more awareness campaigns in terms of prevention that
will result in more people presenting themselves to GUM clinics?
I recall when we were in Manchester one or two of us making suggestions
about preventative campaigns and the people in the GUM clinic
there put their hands up and said, "No, we could not cope
with the additional demand that would arise from what you are
proposing". That is a picture that applies across the country
presumably, a concern that the more the awareness, the more the
demand and the more difficulty in meeting the capacity?
Professor Kinghorn: Yes. We are
in a bit of a dilemma. I wish to encourage people to take responsibility.
I wish to encourage people to take that personal responsibility
for their health and for the health of their partners, but, unless
capacity increases go hand-in-hand with the education campaign,
then there is a risk that services which are under severe pressure
would be in a state of collapse. The concern we have at this present
time is that new resources for capacity may not become available
until 2006-07, which will be after the education campaign has
been proposed. That, in our view, would lead to a great dissatisfaction
amongst the public because we could not cater for the obvious
increase in demand.
Q8 Mr Burns: Do you have collective statistics
or do you have any evidence that when someone goes to a clinic
and they find that they have to wait possibly four, five, six,
10 or 12 days before actually seeing someone then they fail ever
to turn up again?
Professor Kinghorn: Yes, there
is a proportion of patients who will not come. This is particularly
the case with the young. There is a window of opportunity and
it is important that when individuals present they should be seen
at that time, otherwise there is a risk that they will not turn
up and they will continue to ignore symptoms.
Q9 Mr Burns: Do you think it is more
that they will continue to ignore symptoms rather than that they
will try and get help elsewhere, like going to their GP or whatever,
or to another clinic, depending on where they live?
Professor Kinghorn: Some will
try to go to other settings, but I think many will fail to turn
up.
Q10 Dr Taylor: May I go back to the 48-hour
targets for the moment? We gained the impression with the GP 48-hour
target that some practices actually suspended the list at 48 hours
so that nobody was over it. Is there any evidence that you are
doing the same sort of thing, or have you managed to avoid that?
Professor Kinghorn: This is an
issue about which I feel particularly strongly. The 48-hour access
should be from the time that the person first makes contact with
that service. It is not acceptable to me that they should be required
to ring up on succeeding days.
Q11 Dr Taylor: They should ring up every
morning at 8.30?
Professor Kinghorn: I think that
is quite an iniquitous system and should be strongly discouraged.
I think what we are saying is that we wish to have access, if
not immediately, at most within 48-hours from the time that the
person first makes contact.
Q12 Dr Taylor: Going on to funding, you
have already said you welcome the new money but that the resource
is rather less than recommended. What we want to explore is whether
it is actually getting through to you. In the brief, the British
Association said that 90% of the £5 million that was allocated
directly to GUM clinics got through, but not all of the rest that
went to PCTs, and in fact it is so bad that approximately 50%
of the money only reached its intended destination. What is the
answer to this?
Professor Kinghorn: If I may give
some further explanation to this, in 2003-04 there were two allocations.
The first was £8 million of recurrent funding; the second
was £5 million of non-recurring funding. Both of these allocations
were made to PCTs rather than directly to clinics and only half
of all of the clinics recorded receiving their full allocation,
and one-third of the total funding in 2003-04 appears to have
been used for other purposes. In my own city of Sheffield half
of the recurrent amount in 2003-04 was withheld by the PCT, and
their reason was that sexual health and GUM services were not
seen as a priority. I think the answer is that we now have increased
priority as a result of the White Paper. As ever the optimist,
I hope that there will not be a repeat of this in the future.
I think that the other answer which is very important is that
there should be strong performance monitoring by strategic health
authorities to make sure that this cannot happen again.
Q13 Dr Taylor: They should be monitoring
that the money actually gets where it is intended to go?
Professor Kinghorn: Yes.
Q14 Dr Taylor: If you get all that is
proposed, will that enable you to meet the 48-hour target, for
example?
Professor Kinghorn: I can only
say that I hope so. I think that with the potential capacity requirement,
if we encourage everyone who changes their sexual partner to seek
a check-up before they have a relationship with a new partner,
we are talking about a demand for services which is hugely increased
from that which is met by GUM services at the present time. We
are talking here of potentially millions more patient episodes.
I am optimistic that we can do more, but I think we will just
have to see how things develop. I know that within my own setting
we are planning for there to be a 50 increase in new patient episodes
within the next three years. I know that we need to increase community
capacity by two or three times if we are to meet the demands which
are going to be placed upon us, but I am ever optimistic.
Q15 Chairman: Could I clarify that I
understood you correctly to say that when people change their
sexual partners they should have a medical check?
Professor Kinghorn: Yes.
Q16 Chairman: And people who change their
partners several times a night could cause some difficulties,
presumably?
Professor Kinghorn: They will
need to be seen more frequently!
Q17 Dr Taylor: I am wrestling with the
recommendation we have to make because strategic health authorities
have only one aim, and that is to balance their books. If the
PCT does not have enough money even to meet its stated targets,
we are going to have to wrestle with this one. I think we have
the message.
Professor Kinghorn: I think we
also see a role for the Healthcare Commission in making sure that
they are supporting sexual health and that they do have an increased
role in the future in ensuring that the services are appropriate
to meet local need.
Dr Taylor: That is a very good point
and it is something we can stress to the Healthcare Commission.
Q18 Mr Bradley: The White Paper also
announced the introduction of chlamydia screening throughout England
by 2007, with particular emphasis on women under 25. First do
you have any general comments about that aspiration? Secondly,
could you update us on the availability of the NAATS screening
testing in England?
Professor Kinghorn: We are very
glad that the availability of the most sensitive tests will occur
throughout England by 2007. Currently, about 25 of the country
has access to the most sensitive test. I am concerned to ensure
that the most sensitive tests are used for all people, irrespective
of their age, and not just reserved for those women under the
age of 25. Of course, a screening programme based on opportunistic
screening of young women alone has its drawbacks when the prevalence
of infection is about one in 10 of those sexually active women
under the age of 25. The prevalence in young men under the age
of 25 is also about one in ten, or more. It is important that
we should be encouraging young men, as well as young women, to
be screened.
Q19 Mr Bradley: So I am clear, you are
saying there is 25% access to the NAATS test now?
Professor Kinghorn: Yes.
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