Examination of Witnesses (Questions 20-39)
PROFESSOR GEORGE
KINGHORN, MS
ANNE WEYMAN
AND DR
WILLIAM FORD-YOUNG
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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