Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 100-121)


27 JANUARY 2005

Q100 Dr Taylor: You have given us so many arguments, that if there is any logic in the political world at all we cannot fail.

   Mr Nieuwets: But first of all money.

  Chairman: We tried to build a big wall a few years ago to keep the Scots out, but they appear to have got through!

Q101 Dr Naysmith: I think it is time we brought Pam Ward in. She has been sitting there very patiently waiting to be asked a question. One of the things that was in the original consultation paper gave examples of how loopholes in the law allowed overseas visitors to come here, to bring their dependents with them and, according to the White Paper, to abuse the National Health Service. The examples included people living here, flying their wives to the UK for short period to access maternity services, for instance, and people working in the UK bringing their dependents for access to complex and sometimes expensive surgical operations.

  Ms Ward: That is correct.

Q102 Dr Naysmith: How typical do you think these examples are? Do you know of any other examples?

  Ms Ward: The regulations as far as HIV and the charging have not changed since 1988. The only thing that has changed is the definition of ordinary residence.

Q103 Dr Naysmith: We will come to the HIV in a minute. Would you deal with the White Paper.

  Ms Ward: The loopholes you are talking about are quite correct. Because, if you were a student and you had a student visa, that was fine, you could come over on an agricultural course for 12 weeks and you could bring your four children and very pregnant wife, and, as spouse and dependents, they would be entitled to receive treatment at the same time, so they would be exempt. The regulations have changed to say that the dependents have to come for the duration of the stay of the exempt person. Now if you are coming on your six months' agricultural course and you have to bring your wife with you, she has the right to be here as your dependent and stay the duration of your stay. If she just comes over for a fortnight's visit and wants to deliver her baby—which does happen—then she is chargeable.

Q104 Dr Naysmith: How widespread do you think this is? Is it a big problem?

  Ms Ward: It is across the country. In our group we have representation from a vast majority of NHS trusts, and this is the feedback we have at our meetings, that these are the issues that the overseas managers face. These were of course highlighted and taken on board. So, yes, there is this abuse, though it has now changed and it makes it a lot easier to manage.

Q105 Dr Naysmith: You are saying it poses problems for managers to deal with. Dr Asboe was talking about the limit. What did you think about what he was saying?

  Ms Ward: I quite agree. The difficulties from an overseas manager's point of view in a trust is that you have to remember the guidance has to be implemented at a local level and it would be the responsibility of the trust and the way they manage it and set up a structure to manage it. The consensus of a lot of overseas managers is that actually to get access into information in GU clinics and sexual health clinics is taboo: we are not allowed in. There is a lot of hostility against overseas managers even to want dialogue with people in GU clinics. We could not say if we identified patients entitled for treatment or not. There are very good pockets and a lot of people are doing a lot of good work, but generally it is very hard to get access into patients receiving treatment. We just have to work very generally. It is difficult. There is no formal training. You have to decide on the patient's residency—and that is the question. Is this person a resident of the UK or here for a viable purpose and can prove to you that they are here for that purpose? We need documentary evidence to do that. You have to make an assessment on that documentary evidence and what you are being told. Yes, errors do happen and people get charged by mistake, but you should always review patients and the trust has the right to refund money if they feel they have acted wrongly. It is a difficult area for us to deal with. We have to rely on a clinician's decision. An overseas manager can interview a patient, they can have the documentary evidence, and it can be decided then that this person is not a resident of the UK, he is only here for a viable purpose, so they are chargeable, however, we would have to go the clinician and advise him of that and the treatment then would be provided as to its need. Yes, an invoice would be raised and the trust has the responsibility to try to retrieve this money; otherwise we are covering the burden of treating a lot of people who are non resident in the UK.

Q106 Dr Naysmith: You were saying that you have trouble getting access to GU clinics in general.

  Ms Ward: Yes.

Q107 Dr Naysmith: There is a very good reason for confidentiality.

  Ms Ward: That is correct.

Q108 Dr Naysmith: If there is not confidentiality, it can put people off going to clinics. Are you suggesting there is more than that or is it just the normal confidentiality?

  Ms Ward: It varies. You can have hostilities against you because of your role in your trust. As a trust employee, of course, we have signed a confidentiality list. We are part of the same trust; we are all working in the same organisation. We are not asking for confidential information; all we are wanting is to have some mechanism where our stage one questioning of the patient could be identified. If their HIV test comes positive, then perhaps they are referred for a further interview to establish their residency. Once that is established, of course, it will be on the advice of the doctor whether they were a resident or not, chargeable or not. But, yes, it is difficult to get in there generally.

Q109 Chairman: Would you give us some examples of the practical problems you and your colleagues have faced with the HIV charging arrangements. When we had this consultation process, were these examples and concerns put to government?

  Ms Ward: I think a lot of work is being done in small pockets with the large trusts in the larger areas. Trusts have various problems according to their demographic location, so it depends on where the hospital is sited as to what your clientele would be. But I have a trust member's information here, and she has various people attending from asylum seekers, students, visas. It is difficult to get the message across. She is now doing a presentation to her trust board to show them the size of the problem. But, as you rightly say, the treatment for AIDS could go on to be quite costly as an in-patient or a drug regime treatment is very expensive. It can cost the trust quite a burden, if we are not identifying these patients and only treating the patients that are rightly resident here.

Q110 Dr Taylor: I think we have covered the areas I was going to ask about but I have another question, if I may. Could I explore a bit more with you, Peter, your job. You describe yourself as Commissioning Manager for West Sussex.

  Mr Nieuwets: No, it is five PCTs.

Q111 Dr Taylor: That is five PCTs which work together.

   Mr Nieuwets: No, they do not work together actually.

Q112 Dr Taylor: Then Commissioning Lead for Kent, Surrey and Sussex. Is that a strategic health authority?

  Mr Nieuwets: It is a strategic health authority with, I think, 15 PCTs in it.

Q113 Dr Taylor: Then Chair of the English HIV and Sexual Health Commissioning Group.

  Mr Nieuwets: Yes.

Q114 Dr Taylor: What does that consist of?

  Mr Nieuwets: That is a group of people where are a number of stakeholders, the Department of Health and all commissioners for sexual health and HIV are invited to attend. We are restructuring at the moment to become a more independent group. It is also one of the very few fora in the country where commissioners can sit together and discuss the problems they have, problems around: Where has the funding gone? Where has the prevention money gone? How do you deal with the department? How do you deal with your strategic health authority? Because the strategic health authority has been given a role but most strategic health authorities are struggling with their role and lots of PCTs have no clue who within the strategic health authority is struggling with their role. The communications are not always that clear.

Q115 Dr Taylor: But this is an extremely important body.

  Mr Nieuwets: Yes.

Q116 Dr Taylor: Are your decisions acted on? Are your messages taken up?

  Mr Nieuwets: We are listened to.

Q117 Dr Taylor: Right. How can we help you to be not only listened to but, in the words of Hazel Blears, "valued and acted upon" your views?

  Mr Nieuwets: We are working on ways to make our voice stronger and also to have a much stronger role. We are working on that with some of our stakeholders.

Q118 Dr Taylor: But bodies exist to improve things.

  Mr Nieuwets: Yes.

Q119 Dr Taylor: At least that is a start.

  Mr Nieuwets: Recently we had a meeting and one of the people was not allowed to come because her PCT had a deficit and people were not allowed to travel outside the PCT area. It is one of the problems at the moment that many PCTs are struggling financially—and struggling financially across the board. As I have said before, sexual health does not have a high priority. HIV has some priority because it is a big bill for London ending on somebody's desk, so they have to secure money for that, but in general very little money is secured.

Q120 Chairman: Are there any other comments? We probably ought to wish Mr Nieuwets all the best with his future career after that! Could I thank you all for a very interesting session. I am sorry, Mr Evans, did you want a final word.

  Dr Evans: Just one thing on the data. We saw this great rise between 1999 and 2003, and the provisional 2004 data does indicate we have not been going up 20% here but have levelled off. This is new diagnosis for HIV. There is some evidence that we are eating into the undiagnosed fraction and we are beginning to level off. At high levels—we are probably going to end up with 78,000 new diagnoses last year—but we are no longer in the 20% rise a year. That may have political consequences of we are no longer on the steep trajectory of an increasing issue.

Q121 Chairman: Have those figures been made available to the Committee?

  Dr Evans: They have not as yet. We will make sure they are. We are about to publish those figures and we will make them available to the Committee.

  Chairman: I am very grateful to you. Thank you all very much for a very useful session.

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