Examination of Witnesses (Questions 180-199)
MISS MELANIE
JOHNSON MP, MS
ELIZABETH RYAN
AND MR
GEOFF DESSENT
10 FEBRUARY 2005
Q180 Dr Taylor: Firstly, perhaps I could
follow that up. Would it be possible if we, as a Committee, or
I, as an individual MP, put in a PQ to ask for a list of all the
PCTs' costs of their local delivery plans?
Miss Johnson: No, I do not think
that is possible because the local delivery plans are formulated
by them. We have looked centrally at what we think the needs of
the services are across the country. We cannot divide that up
against the local delivery plans. They will cost out their own
delivery plans. I know what I was going on to say. You mentioned
deficits, but historically the Health Service has been in financial
balance over the last four years, so this position about deficits
is a bit of a moot point and at this time in the financial year
the apparent deficits always look rather worse than the outturn
at the end of the year as well. I think because it is such a moving
picture, it is very difficult to be clear about this, but we regard
the money that went out yesterday, including this money, as additional
money, not needed to meet any so-called deficits and actually
available for the improvement of services and access and all the
other things that we have been talking about.
Q181 Dr Taylor: So the only way for us
to find out the cost of each PCT's local delivery plan is for
each MP to contact their own PCT and find that out?
Miss Johnson: Well, I assume the
cost of their delivery plan will be their budget. They have got
a sum of money and in order to deliver that, they will be producing
a delivery plan actually to meet up with the budget that is available
to them.
Q182 Dr Taylor: I would have thought
that the development of a local delivery plan goes through a process
before that. You decide what you want and the cost of that and
then you have to cut that down to the money that is available.
Miss Johnson: This is a normal
process at all levels of anybody controlling any expenditure in
any arena of life. I think we would all wish to have fantasy sums
of money available to do all sorts of things which we are never
going to be able to do, so I think we have to accept that we would
all be able to sit around and think of things that we could do
with more money, publicly or personally, but that is not the reality
of the world. There are record sums of money going out to the
Health Service. The increase has been absolutely phenomenal in
Health Service funding.
Q183 Dr Taylor: No, I am not arguing
with that and I am clearly not thinking of fantasy either, but
I can see a picture where the demands of sexual health services
are possibly at the bottom when they are pitted against the demands
for developing cardiac surgical services and cancer services.
That is all I am trying to get at.
Miss Johnson: In the days in 1997
when there were 18-month waits for hospital inpatient treatment
for some people, there was a lot more difficult weighing up of
priorities to be done, whereas now our aspiration is to get to
18 weeks from start to finish of that process and where we are
already under nine months and will be under six months by Christmas,
so of course there is always a weighing up of priorities. Everybody
has to weigh up priorities. The Government has to weigh up priorities.
Whoever you are, you are weighing up priorities, but I would say
that having been a local authority member in difficult times in
the 1970s, 1980s and 1990s, actually I know that those difficult
decisions were actually in the arena of cuts and actually where
you cut, not where you expanded and how much you could expand.
There is a very different climate for people running the services
today in the public from what there was in, say, the late 1980s
or early 1990s.
Chairman: You talked about the mechanisms
that you have put into place to ensure that the funding is actually
spent on the purpose, and we welcome that and want to see some
positive outcomes. One of the things that really caused me concern
when we looked at sexual health was the way in which the service
in some areas was so substandard that I think all of us were shocked
at what we saw. What we were trying to establish was how that
could happen, how it could be that those organisations responsible
for that service had allowed that service to deteriorate to such
an extent that some of the facilities were, frankly, appalling.
Obviously we came to some conclusions, one of which was that this
is an area which is, and I was going to use the words, "not
sexy"—
Miss Johnson: Yes, I do know exactly
what you mean.
Q184 Chairman: It is not an issue that
you or I, as local MPs, would get constituents writing to us about.
Therefore, politically we are not under pressure to do a lot about
this area. In the context of the move towards devolving decision-making,
and I personally support the direction the Government is going
in, how do you square that problem that possibly in certain areas
they will not want to make, as Richard says, investment in this
area because it is not something they are under pressure to do,
how do you balance that with trying to reduce the amount of central
directives which to some extent you have just described and how
do you square that up with devolving the power to local people
and letting them make the decisions in their own back yard?
Miss Johnson: Well, there is always
a balance to be struck, is there not, so, for example, we have
taken the decision that there are improved tests available for
Chlamydia, that we want those tests rolled out, that we want a
national screening programme, that we are going to have that,
that that is going to be put in place, that resources have been
deployed behind that investment and that that is not a matter
for local decision-making, as it were, and that there is going
to be a national campaign because we think campaigns need to be
run nationally rather than regionally or locally, although they
could be backed up in that way, so some of those things need to
be done on a national basis. Some of the frameworks, some of the
demands and standards and the monitoring all need to be done nationally
and, within that, I think we want to devolve as much as we can
to a local level. I agree with you that I think historically sexual
health and particularly the clinics themselves have been a forgotten
area and they have certainly not been sexy, in the way that you
are saying, and it is exacerbated by the fact that people do not
write to us, complaining that they had to attend the clinic and
how appalling it was or whatever historically. It has now come,
I think, very much to everybody's attention that more investment
needs to be made and that is why we have made the investment.
We need continually to monitor that, but I think for the first
time now as well that the commissioners of those services, and
we have to remember historically that a lot of what we are dealing
with goes back many years and indeed the Portakabins or whatever
go back many years as well that it was taking place in, or still
is in some areas, actually it was not the PCTs commissioning in
those days. They have got sexual health needs now in the PCTs,
we are building networks for the sexual health needs, we are doing
more to look at information about training sexual health workers
and we are doing a lot of things to support the service, to network
the service and to make the commissioners much more aware of the
demands on them, plus the formal performance management side of
it, which I went through earlier on and I will not repeat again
now.
Q185 Dr Naysmith: In evidence to this
Committee Dr Ford Young, who is a general practitioner who has
a special interest in sexual health, told us that in the area
of sexual health there had been a great missed opportunity when
the new GMS contract was being negotiated. Do you share that view?
Miss Johnson: No, I do not. Why
did he feel that because that was a statement, it was not a set
of reasoning?
Q186 Dr Naysmith: Well, one of the arguments
he had was that the essential services element of the new GP contracts
should have included sexual health and that there would have been
an opportunity there to take all sorts of steps that there is
no incentive to take now for GPs. It is not incentivised at all
under the new GP contracts, that GPs should involve themselves
in this sort of area, and there are lots of things that GPs could
do in this area.
Miss Johnson: Well, PCTs can contract
in a whole variety of ways for this. They can use a lot of the
medical contracting routes available to them from general practice
sexual health services which can be tailored to meet needs using
various different routes, the GMS route, the PMS route, the alternative
PMS route and the PCT-led medical services, so there is a whole
lot of avenues there that are open for contracting purposes, and
there is the enhanced services aspect as well, so there are a
lot of ways in which sexual health services can be delivered and
practices indeed are continuing to offer consultations and examinations
and so forth as well.
Q187 Dr Naysmith: Apart from all these
acronyms, you obviously said that the PCTs "can".
Miss Johnson: Well, I have already
dealt with the issue about what the pressure is on the PCTs and
I hope it is clear that there is a lot.
Q188 Dr Naysmith: I know, but the argument
was that this ought to have been part of the essential services
because, as you know, the essential services are things that PCTs
must do.
Miss Johnson: Yes.
Q189 Dr Naysmith: Infections, and some
of them can be life-threatening infections, should be treated,
should they not?
Miss Johnson: They certainly should
be treated. If they are ill, they certainly should be treated.
Q190 Dr Naysmith: Instead of just saying,
"You've got to go down to the Portakabin down the road."
Miss Johnson: In fact, the vast
majority of these are not life-threatening, although they are
things that we want people to be treated for. They are mostly
one course of treatment, as I know I do not need to explain to
you, with the exception of HIV/AIDS.
Q191 Dr Naysmith: So what you are saying
is that syphilis and gonorrhoea, both of which seem to be on the
increase in some parts of the country, are also life-threatening
diseases, as well as AIDS. Are you saying the Department is quite
happy with the situation and does not intend to review anything
to do with the GP contract?
Miss Johnson: I am sure over all
we will be looking at the way in which the GP contract is working,
but it is not to say that we anticipate any formal reviews, including
formal review in this particular area.
Q192 Dr Naysmith: What steps can PCTs
take then to incentivise GPs to undertake some of this work?
Miss Johnson: They will be the
commissioners of service, so they are in the same position as
really anything else. If local GPs do not want to offer a number
of services now, they are not obliged to offer them. The PCTs,
however, have the money and the money follows services, as it
were; it follows the patient. This is increasingly going to be
a powerful tool in the Health Service, I believe, for delivering
the quality of services we want, delivering the access that we
want and we should get, and also being able to use the money flexibly
to deliver that in a number of settings. In this particular case,
I think the role of the clinics is very important and we want
to see the clinic provision maintained, with a better quality
and better access, but equally well, there are a number of other
avenues. We have recently been going out to tender on some publicity
on some of the Chlamydia testing arrangements, and there are opportunities
for some of these services to be provided in a very different
way in the future, a way that I think will suit the generation
that we are particularly focusing on, and a way which will make
it more tailored to people's everyday lives and what suits them
in terms of ease of access, timings, and so forth.
Q193 Dr Naysmith: Mr Bradley is going
to ask some questions about Chlamydia in a minute or two, but
this is an absolutely obvious area, because there is evidence
that large numbers of GPs, maybe as many as 50 per cent, are interested
in providing Chlamydia, but at the moment there is no incentive
at all; there is no reimbursement for GPs under the current circumstances
for doing it. Are you saying GPs are going to be allowed to be
part of the bidding process to provide Chlamydia screening?
Miss Johnson: We have arrangements
in process for rolling out the testing for Chlamydia screening.
We have not got through all the detail of how that will be done
at the moment, but the aim is to get all of the Chlamydia screening
across all of the strategic health authorities by April 2006[12],
so we want to have all of that screening in place. The GP does
not have an incentive to treat me particularly when I turn up
with whatever everyday complaint there is. I am not quite sure
. . . You know, they are paid.
Q194 Dr Naysmith: They are paid to diagnose
and send off to consultants where it is something tricky and they
want a second opinion and so on, but there is quite a lot of sexual
health which can be treated in primary care, and there is no incentive
in the contract, we were told, at the moment for GPs to do that.
Perhaps we could ask Mr Dessent if he knows—obviously, with
your permission, Minister, since you are in charge of that end
of the table—whether when the contract was being negotiated
the area of sexual health was considered as something that might
be included in essential services.
Miss Johnson: Before he makes
any comments on that, can I just say there are a lot of different
providers who are clearly very keen to provide, and when you say
GPs can obviously do this, obviously GPs can, and we hope that
they will continue to do so, but we are looking for a mixed economy
so that there is a variety of patterns of provision that both
meet the individual needs of that particular community, as it
were, rural, urban and all the rest of it, but also meet the needs
of different sections of the population. For example, community
pharmacies may well be one route in a community setting. The GP
is one community setting alternative for the provision, but it
is by no means now the only alternative, because clearly, there
are a whole variety of other forms of provision growing up, which
are increasingly very well supported by the public and which they
find very convenient and which we want to increase where that
is appropriate.
Q195 Dr Naysmith: I do not know if Mr
Dessent wants to answer the question, which was not just about
Chlamydia but about general sexual health services.
Mr Dessent: Obviously, in terms
of the development of the GMS contract, yes, of course we were
involved in discussions about that, and made the case for where
it might be introduced. I probably should say that there will
be at some point a formal review of the GMS contract, and we will
be making those same arguments again to see whether there are
particular avenues that might be explored that would start to
address some of the points that you are raising, and certainly
Chlamydia is one of the issues that we particularly recognise
as being relevant to this.
Miss Johnson: We will have at
that point a lot more provision on the ground than we currently
have, and it would be interesting to see how that is developing.
Q196 Dr Naysmith: The other thing, changing
the topic a little bit, is that if we are going to have these
increased services, there has to be an increase in the amount
of training that goes on.
Miss Johnson: Yes, indeed.
Q197 Dr Naysmith: It has been suggested
to us that, if we are going to have this increased capacity within
primary care, GUM clinics and contraception services as well,
we need a separate training budget and a formal national training
programme for doctors and nurses, both at the pre-qualification
level and the post-qualification level. In particular, it was
suggested to us that GPs and practice nurses have a pressing need
for training in this area. Are you aware that there is a problem,
and do you have any plans for addressing this?
Miss Johnson: It is quite interesting,
because, as you know, we have recruited about 80,000 extra nurses
over recent years to the NHS as a whole, and what I have been
quite struck by as I have gone about my travels is the number
of people I meet in primary or community care settings now who
are ex-hospital. They may be cardiac nurses, now doing cardiac
rehabilitation in a community setting, when they were formerly
working in the cardiac units in the DGH or whatever, or other
people who have moved out to provide other services in other settings.
I have come across quite a lot of these people in treatment centres,
in the community, working for GPs, working in out-reach work.
I am not sure what the work force patterns would show but my suspicion
would be that there might be a bit of a drift of people from acute
settings, with a lot of very relevant experience, now providing
an allied or very closely related service in a community setting.
But, of course, because we want more provision in the community,
we do need more work force in that area. There are work force
planning arrangements, and strategic health authorities have a
role in this regard. I think in a lot of communities growing people
on through roles in the NHS and allowing them to get qualifications
is a very important part of that. I met somebody working in mental
health, who was responsible for a unit, who had started off as
an untrained nurse and had been allowed to go off as part of that
and get the training, and then return to the unit. This is where
it is having advantages for those communities, that people are
being skilled up by the NHS, who are a major local employer in
many settings, and particularly in areas where employment options
are still not as rich as they may be in other parts of the country.
I think there are a lot of avenues there. On the sexual health
side of things specifically we have . . .
Q198 Dr Naysmith: A lot of the things
that you have just been talking about have involved specialised
training for these nurses and doctors in the NHS, and we are saying
we need it in the sexual health field.
Miss Johnson: Yes, I am just going
to answer that point. We have actually undertaken a mapping of
training needs and produced some recommendations and an action
plan on that. There has been a day held with stakeholders which
led to a national working group—this is on training—being
established in partnership with the Centre for Sexual Health in
Sheffield, so I think this is very much meeting up with the point
you are making, and its terms of reference are to do things like
take forward the action plan for training, agree quality standards,
make sure there is consistency in training—this is for sexual
health professionals—and to work towards national accreditation.
There is a distance learning package as well for nurses, that
has been published and accredited by the University of Greenwich,
and there are also some key competencies published for sexual
health nurses. I think increasingly we are looking at diversifying
our work force and giving them specialist skills in particular
areas of provision. Sexual health is probably just one example
of that, and I think the wider skills mix that we therefore need
is something which, across the Health Service, we are having to
address, but in this particular way we are addressing it like
this.
Q199 Chairman: Before we move away from
training, I mentioned that last week I had visited this sexual
health project in my own area. It is a West Yorkshire-wide sexual
health project. I asked them about the use of primary care, saying
that one of the things that the Committee felt was that we could
make more use of alternatives to GUM within the community. You
have mentioned pharmacies. I certainly felt that GPs could probably
do a lot more than they do now. Their response, particularly from
the perspective of dealing with lesbians and gays, was that they
had had some very negative experiences. The local service co-ordinator
faxed me subsequent to the meeting to say the reason he would
always direct to a GUM clinic—that is, his clients—is
completely due to the number of poor consultations that service
users have experienced at their GP's. I think he is talking of
West Yorkshire, not just my own area. He gave me one or two examples
of quotes given to him by users of the service. One young girl
was told, and I quote, "You are too young to know you are
a lesbian." This is, obviously, a GP, according to the person.
Another girl was told "You are gay. Have you had any counselling?"
A young man who used the service said, "I told the doctor
I was gay and he immediately wrote `HIV?' in my notes." What
they are saying to me is that there is a need for training of
GPs to include not purely medical screening, STI screening or
whatever, but sexual health consultation, which in their view
in many instances in my part of the world is done rather insensitively.
We might be an exception to the rule, and I suspect we are talking
about a minority, but would you feel that this kind of area could
be addressed in looking at the training needs that Doug has referred
to?
Miss Johnson: I think that is
a bit different because if you are talking about training of GPs,
that is really a matter for the curriculum; both the initial curriculum
and post-graduate training is really a matter for the Royal Colleges.
They are in charge of a lot of what happens on all of that, both
the nature of it and how it is delivered as well. We obviously
do have dialogue with them about training, and various parts of
the Department and through the Chief Medical Officer, we have
links into the Royal Colleges and what they are doing, but it
is a matter for them, and I think it would probably be most useful
to discuss those issues with them. Obviously, we are always concerned
if GPs are not giving patients an appropriate response, and I
take it that the PCT may be interested to know that and may want
to pick those issues up with some individuals or some practices
themselves in an informal way.
Chairman: These may be isolated examples,
but, as I am sure you will appreciate, if that is the kind of
response you are getting, it is not exactly encouraging a person
to continue using the Health Service when they may need to.
12 Note by witness: The commitment made in
the public health white paper, Choosing Health . (Department
of Health, 2004) Is that " we will accelerate implementation
of a national screening programme for Chlamydia, to cover the
whole of England by March 2007. However, additional investment
to help laboratories switch to the nucleic acid amplification
test for Chlamydia has already been allocated in advance of this
roll-out, and it is anticipated that all areas will have access
to this method of testing by April 2006. Back
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