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
Chairman: We tried to build a big wall
a few years ago to keep the Scots out, but they appear to have
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
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 babywhich does happenthen 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
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
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 residencyand 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
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
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
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
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 financiallyand 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 levelswe are probably
going to end up with 78,000 new diagnoses last yearbut
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
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.