Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 20-39)


27 JANUARY 2005

  Q20 Mr Bradley: By 2007 what percentage do you think will be available for that?

  Professor Kinghorn: I am assured that the programme intends that all areas of the country will have access to the most sensitive tests, but the availability of such tests in all areas may not necessarily be the same thing as access of all patients to the most sensitive tests. It is important that diagnostic services should be equally available for all who need them.

  Q21 Mr Bradley: But you do not believe that will happen by 2007 for all categories?

  Professor Kinghorn: I hope that it is going to be available by 2007, but I think there may well be difficulties in achieving that date.

  Q22 Dr Naysmith: Could I bring in Dr Ford-Young now and talk a little bit about primary care services as they have been mentioned. In 2001, the Sexual Health and HIV Strategy envisaged a crucial role for primary care in this area. As we understand it, the new GMS contract does not offer much in the way of incentives to do that, so do you think there has been a missed opportunity? Perhaps you could help us understand the issues surrounding that and why there are not incentives?

  Dr Ford-Young: I think there has been a great missed opportunity in our new GMS contract. GPs who have an interest in sexual health, like myself and my colleagues, very much welcomed your report in June 2003, and you recognised the potential that general practice and other parts of primary care have in delivering good quality sexual health services. We see a lot of patients through our doors. We provide up to 80% of contraception services in England and, in a way, we are the sleeping giant of sexual health services. Your Committee and we ourselves were optimistic that our new contract would help improve the provision of quality of care for sexual health but, unfortunately, it does not. It appears to have ignored the National Strategy for Sexual Health and HIV.

  Q23 Dr Naysmith: Why do you think that is?

  Dr Ford-Young: I think it has ignored the levels of care that exist within the National Strategy for Sexual Health. Basically, we have a three tier contract. The most basic level is what is termed essential services. That is for us to react to patients who walk through our doors who are ill, or believe themselves to be ill; to provide management for chronic disease; and to provide terminal care. Within that, I think I, as a general practitioner with an interest in sexual health, would include sexual health as part of general medical services because sexual health is part of our health and wellbeing as human beings. I think, however, the negotiators who negotiated the contract felt that sexual health was not part of essential services. Whilst the national strategy provided holistic levels of care for all the various parts of sexual health from contraception to STIs and cervical cytology, et cetera, our contract decided to place these various elements of sexual health into various additional add-on bits of our contract over and above essential services. The only part of our contract that really encompasses sexually-transmitted infections is what is called the National Enhanced Service, which is very much a high level, add-on bit of the contract. There would be very few practitioners in the country who would have all the skills and competencies to provide that service. In my experience, there are very few PCTs that are commissioning that kind of service.

  Q24 Dr Naysmith: Would it enable some practices to specialise in this sort of area of medicine for a particular part of a city or something? The system is there but you are saying you think it is unlikely to happen?

  Dr Ford-Young: That is possible. It is happening in some areas but there is a reluctance, I think, by many PCTs because of what they see as financial constraints and where they see the importance of sexual health on their agenda to decide to commission such services. We lack any formal national training programme to upskill general practitioners and their nurses, and so on, to provide these services. We need to include general practice as a good site for chlamydia screening, but screening is not seen as an essential service, so again that needs to be supported and resourced. I am aware that the Department of Health is looking at a model whereby it could be formed as an enhanced service into general practice, but that does need the commitment from the Secretary of State to provide the resource to do that. We need to look at the competencies involved for that, and so it is not going to happen overnight.

  Q25 Dr Naysmith: In a kind of anecdotal way, how do your colleagues feel about this? Would they like to get more involved in it if there were more incentives? When we were doing this last time round, we all agreed that we, as Members of Parliament, hardly ever got any complaints about sexual health services. We get complaints from constituents about all sorts of other things but rarely about sexual health services. I wondered if the same kind of thing applies amongst professionals. Is it low down on the horizon?

  Dr Ford-Young: I think people's perception covers a wide range and where they themselves as general practitioners would put sexual health on their agenda. Generally speaking, certainly anecdotally from my area where I have been involved in trying to roll out a chlamydia screening programme at a phase two site, of my colleagues who unlike myself do not champion health but feel that chlamydia is an important cause, over 50% in my area wish to be involved in the chlamydia screening but see the contract as getting in the way of being able to find the resource in time to provide that service.

  Q26 Chairman: Could I ask you about an issue that obviously struck us all when we looked at sexual health two years ago and it was that as MPs I do not think any of us had received any representations from constituents about problems with GUM services or accessing services. At that point, I think all of us saw a dilemma. In the process of moving decision-making on health care more and more towards local people through PCTs and decision-making in the secondary sector as well to local people, that same problem of us being unaware of what was happening would be shunted to local decision-makers from national decision-makers. How do we get an awareness of the kinds of problems we are talking about here today across to those people who are making the decisions that result in Professor Kinghorn only getting a small part of they money he ought to be getting? Do you understand the problem I am describing? Money is a difficulty which we felt, as a committee, was hard to challenge and how you got this awareness across that enabled you then to direct the resources where they were needed.

  Dr Ford-Young: One of the things we probably need to look at and support, and again it does need support from the centre, is managed clinical networks. When we lost health authorities and moved to PCTs and we were shifting the balance of power, we actually lost a lot of expertise and competence around commissioning sexual health services, especially some of the more specialised sexual health services like HIV treatment and care. I feel a PCT is too small a body to be commissioning at that level because the more specialist services lie across several PCTs. In the implementation plan of the national strategy it suggests that we should be looking at more joined-up commissioning of primary care organisations working together. There is a good example, I think, of a managed clinical network in Greater Manchester, which covers the strategic health authority area whereby I think a lot of the problems we had with shifting the balance of power can be addressed, still at local level, without everything coming from the centre nationally. A managed clinical network like that helps to link the various service providers from a GUM clinic to an HIV provider to a general practice or a community family planning clinic or a voluntary organisation. It can help to have all those service providers providing a basic minimum standard of care, which would be a good standard of care to ensure patient care pathways exist. All too often we forget that the patients should be at the centre of our care in our pathways rather than developing our services to suit ourselves. I think they will be the drivers in the clinical governance issues to ensure good value for money in those areas and to ensure that patients actually get the choice and the service they need and deserve.

  Q27 Dr Taylor: Can I go on and explore that a bit further because managed clinical networks are thrown up as the answer to so many of the specialties in difficulty. How does Manchester actually work? Could you give us some detail? Are there any other managed clinical networks that are co-terminus with strategic health authorities? For cancer, cancer networks are not co-terminus with strategic health authorities, and that always seems to me to be a bit odd.

  Dr Ford-Young: I do not think necessarily a managed sexual health network needs to be co-terminus with an SHA but I think that is useful because of the SHA's hopefully increasing involvement in quality and performance management, perhaps with the extension of local delivery plans at PCT level. This is something else and I think a managed network can help co-ordinate PCTs to incorporate sexual health in their local delivery plans so that sexual health does get on the agenda at PCTs.

  Q28 Dr Taylor: So a network should really be just a central unit with the consultant travelling out to outreach clinics and involving the GP specialists as well?

  Dr Ford-Young: I do not think you necessarily need to have the consultants travelling out. I think the network allows people to stay where they are in their service providing their service, but the network helps to co-ordinate those different elements of care. I think the important thing is that it is a managed network and that resource is found actually to manage it, so that we do not rely on people's goodwill to come to a meeting at lunch time from their work to try to get round a table, but that there is a facilitated network.

  Q29 Dr Taylor: Going back to the GP specialists, because again in geriatrics and in palliative care GP specialists are seen as the answer until there will not be any poor GPs left. How many GP specialists in sexual health are there? Have you any idea?

  Dr Ford-Young: I do not actually know, and I am not certain that the Department of Health's Sexual Health team knows either.

  Q30 Dr Taylor: It is probably very few?

  Dr Ford-Young: I think there are very few who are actually employed as GPs with a specialist interest in sexual health. There are also GPs like myself who have an interest, but we are not actually classified as GPs with a specialist interest and contracted as such.

  Q31 Dr Taylor: So there is a difference?

  Dr Ford-Young: There is a difference, yes.

  Q32 Dr Taylor: You have already hinted that there is not much training. What would be the ideal way of training and attracting more GPs to take on this?

  Dr Ford-Young: I think we very much need to look at driving and funding a nationally-agreed training programme organised through professional bodies such as the Royal College of General Practitioners, the Royal College of Physicians and the Faculty of Family Planning, for example, because we need to be looking at sexual health holistically. A very good model was developed around the management of substance misuse in general practice because there was the will by Government to fund that and the will of the Royal College of GPs to take that on board and develop a course. I think a similar model would work well for sexual health in that managing sexual health, like managing substance misuse, is often seen by many as a not very nice thing to be dealing with, and a client group of people may have some problems in dealing with it, too. I think that has very much helped to normalise the care of people who have substance misuse. One of the most important things we need to do with our care is to normalise talking about sex and sexual health in all care settings, but particularly in general practice.

  Q33 Chairman: What drove you to specialise in this area? If you were in Manchester or London or wherever I could understand, but Macclesfield? Sir Nicholas Winterton is a very good friend of mine but I do not get the impression there is a great deal of sex going on in Macclesfield!

  Dr Ford-Young: I can assure you there is a lot of sex going on in Macclesfield, regardless of whether Sir Nicholas is our MP or not! He is a good friend of mine as well. I have always had an interest in sexual health and I have always worked part-time in GUM clinics as well. In fact, I work in one in Withington, as well as the one in Macclesfield, as well as being a GP. I am fairly unusual in that. A lot of my GP colleagues, whilst they do not wish to work in a GUM clinic as well as in general practice, still have a firm desire to provide good quality sexual health care holistically to our patients because we are generalists and are finding it very difficult to be rewarded to do that. Also, PCTs do not have any sticks to beat us with if we do not come up with the goods, so we have no carrots or sticks basically in sexual health in general practice.

  Q34 Mr Burns: Professor Weyman—

  Ms Weyman: May I say that I am not a professor. I do not know how that crept in and I am very flattered.

  Q35 Mr Burns: You obviously are not a politician because, if you were, you would not have admitted to that! As you are aware, the White Paper has announced an audit of contraceptive services during the course of this year. Would you like to share with the Committee your observations on that, and also the scope and the quality of the services currently provided across the board?

  Ms Weyman: We greatly welcome the fact that there is going to be this audit of contraceptive services. We feel that contraception has been very much the neglected area of sexual health for a long time. Just as we have heard all the problems that there are around GUM clinics, the problems around contraceptive clinics are many: the lack of resources; problems of premises; problems about having insufficient staff to run them. There is a huge number of problems. We do very much welcome this audit but we think it must be something that really is quite comprehensive. As Dr Ford-Young has said, a great deal of contraceptive advice is provided in general practice in England, and so the audit must look at what is going on in general practice as well as looking at what is going on in community clinics and take that comprehensive view. As I say, we are aware of the variability in the quality of services, not only those from general practice but also within community clinics as well. There is a question about looking at how the full range of contraceptive methods is provided so that there is proper access to the full range, which is patchy in many areas. This is partly a question of the skills and capacity of professionals but also about the funding that they have access to in order to provide particularly the longer-acting methods, which in the short term are more expensive. So this is a really important review. We do very much welcome that it is happening.

  Q36 Mr Burns: Do you have high hopes for the outcome of it?

  Ms Weyman: The review is the start, is it not, and it is really about what happens after that and how we go about improving the services that are available. I think there is a great deal of work to do there both in terms of the investment that is required—and we have a certain amount of money set aside for that but we do not know until we have done the review whether the amount of money is in any way going to match up to what is needed to be done—and also in terms of looking at who the professionals are who are going to provide the service, the doctors and nurses who would be involved, and how they are going to be trained. One of the problems at the moment about attracting people in to work in community clinics is the way they are paid compared with other areas of health care. There is a whole range of questions that needs to be looked at to ensure that we have the physical capacity in terms of places but also the people who can provide that services as well.

  Q37 Mr Burns: If we can move on to the actual services, as you are aware, since the publication of the Sexual Health Strategy, there has been a number of initiatives set up to evaluate an integrated sexual health service bringing together GUMs and family planning services. How is that progressing, to your mind? Do you have any general comments on the initiatives so far?

  Ms Weyman: I think this whole question of how you look at sexual health and sexual health services together is still a very big and an unresolved one. If you look at the way the White Paper is constructed and the way the funding is constructed, it is all constructed in terms of individual services rather than thinking about the experience of the person who is coming along to make use of those services. So I think there is a conceptual level which has not really been taken on. The managed network is already talking about the management of something, but you need a strategy that is going to take account of all these different aspects and be working out how they work together. Integration of specific services is one thing; but the integration of how you think about sexual health as a whole and how you plan it and how the budgets are structured is another thing, which in many areas is not on the agenda. Some of those divisions are quite interesting. If you look at it in most areas, for example the budgets and the commissioning of services for contraception and abortion are separate. They really ought to be brought more closely together. There should be more integration between those aspects of the services as well as discussions about the relationship between GUM and contraception. In terms of some of the things that Professor Kinghorn was talking about, such as testing for STIs in other settings, unless you get those services up to standard, those settings will not be there either. There are lots of different issues about making sure that you are thinking about it as a whole so that the various elements are of a sufficient level and capacity for you to think about service delivery in a more related way as well.

  Q38 Dr Naysmith: I wanted to ask Anne Weyman very quickly—and I know Simon Burns said she was not a politician but this is a slightly political question—what she thinks is the driver for the White Paper to announce the audit of contraceptive services? What is the background to it? Is it perceived as really something wrong that has to be put right or is it a reaction so that we remember that a few years back we were all talking about taking clinics out of the community and giving them to GPs? This may be an opportunity to switch over. Do you think at last that concern has got through or is it for some other reason, or have you just been beating the drum?

  Ms Weyman: I hope it is because, first of all, in your own Committee's report you highlighted problems around contraception, the quality of services and the difficulties of assess. It is something we too have been talking about for a long time. Again, one hopes that the message has come through. In this area as well people do not come forward and complain about the quality of the contraceptive services that they are getting. Often I do not think that women have the knowledge that they are being denied methods of contraception; they do not know that all these methods exist because nobody is telling them about them. I do think that a lot of that has come from the pressure that we collectively have been putting on to have the services looked at and the needs that there are. I think there is also recognition of the problem. If you look at the relationship between conceptions and abortions in different parts of the country, there are very great variations, and in many ways that gives some indication, I would say, that contraceptive services are not always meeting the needs, because quite clearly they are not preventing as many unwanted pregnancies as they could be. If one is looking at the way the best compare with those with the worst records, you can always see considerable room for improvement.

  Q39 Chairman: Anne Weyman mentioned a few moments ago the link between abortion and contraceptive services. You will recall that in our previous report we made some recommendations regarding abortion provision, none of which has progressed into the White Paper. I wonder what your thoughts are on this and the implications of the Government not perhaps picking up the concerns we expressed.

  Ms Weyman: We were disappointed that abortion was not mentioned in the White Paper because there are many issues, as you highlighted in your report. There has been some progress in relationship to the provision and access of abortion services over the last few years with the under 10-week abortions being within the balanced scorecard for PCTs, and with some central investment going to PCTs to help them improve, but there is still a huge variation. If you look at questions around access, there are two measures that you can use: one is the difference between those women who get their abortions before 10 weeks, and in the 2002 figures the variation was between 9% and 79% at the top and bottom of the range, and the numbers that are funded by the NHS, which is another measure of access, and the variation was between 46% and 97%. So we are still seeing huge variations in these measures of access. There is a great deal more to do. We do not have detailed PCT figures for 2003; they have not been published. We know that in many areas there are still long waiting times and that there is a lack of choice of method, lack of availability of the early methods for medical and early surgical abortions as well. There still is an enormous amount to do. Another particular area is access for abortions at later gestations where in some areas it is almost impossible for women to get their legal entitlement. We receive quite a lot of calls on our help line from women who have been told they are too late when they have come perhaps at 12, 13 or 14 weeks. There are still many areas to be addressed. We hope that in the implementation plan for the White Paper these will be picked up alongside the other issues that have already been mentioned in the White Paper.

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