Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 180-199)


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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