Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 200-219)


10 FEBRUARY 2005

  Q200 John Austin: Can I just come back to something on the GP contract and GP services in relation to contraceptive services? The FPA in their evidence suggested that the GP contract's lack of quality points for the provision of contraceptive advice undermines this aspect of the contract and does not incentivise general practice to provide a comprehensive contraceptive service. They have also raised concerns about the introduction of PBR, payment by results, and suggested in the area of contraception, as an example, it could militate against the provision of longer acting contraceptives in favour of repeat prescriptions of oral contraceptives instead. Would you accept either of those criticisms?

  Miss Johnson: I would have no reason to believe that, but I would be happy to write to you on the second point. On the first point, we have recognised through the White Paper and through the investment that is going in that we do think more investment needs to go into contraceptive services. That is why we have an audit of what contraceptive services are available going on, and that is why we have already made £1 million of investment anyway this last year to improve contraceptive services. There is £40 million additional being supplied to address gaps in the service on the back of the audit that is being undertaken. We have also established a group to develop an action plan for improvement to the services, so there is a nice guideline being developed on long-acting methods of contraception which we think will raise awareness and usage, and we have also allocated money, £200,000, to support nurses to undertake the distance learning programme specifically on contraception. That will train 2,700 practice nurses in basic sexual health skills and supplying of condoms and emergency contraception. There is a range of provision going on. I think we do need to see improvements in contraceptive services, and that is why we identified the money to do so.

  Q201 John Austin: So the audit will include general practice contraceptive provision as well as family planning clinics?

  Miss Johnson: Yes, yes.

  Q202 Mr Bradley: Minister, can I go back to Chlamydia screening? You have made some comments already on it. We have had evidence that 45 per cent of Chlamydia tests are still being performed using the suboptimal test. Can I take it from your previous answer it is the intention that the NAA test should be applied in all cases by April 2006?

  Miss Johnson: Yes, that is the intention, because the other test has many more false results on it, particularly false negatives. We do not want to continue to use it longer than we have to, but obviously people need to be trained, the facilities need to be there to use the new test, and staff need to be trained in doing so. It is like any of these changes on national screening; you have to have a roll-out period, unfortunately.

  Q203 Mr Bradley: That roll-out period is April 2006.

  Miss Johnson: Yes, that is the aim, to get 100 per cent coverage, all the strategic health authorities involved by that date.[13]

  Q204 Mr Bradley: Secondly, therefore, if we are going to have a national screening programme, it should apply to all ages and both sexes. You are obviously agreeing with that, so why is the current emphasis on women under 25s and not men?

  Miss Johnson: It is not, actually. In the interviews I have done myself in the last few days I have been emphasizing young men as much as young women. Obviously both sexes are infected, otherwise the problem would not be there at all. We need to make sure that both sexes come forward. In fact, we have specific screening programmes running around prisons and also MoD facilities, so there is some specifically targeted largely at the male population, but we want to see both sexes come forward for screening. I think the risks are broadly the same for both of them. I do not think there is quite so much evidence of the infertility for males but there is still evidence of a serious risk of infertility there, as there is quite a lot of evidence that it has that consequence for women and, because it is asymptomatic, we are very concerned that people are tested, and it is so easy to get treatment.

  Q205 Mr Bradley: So the campaign, when it is launched, will cover the whole spectrum?

  Miss Johnson: It certainly will, yes. I think one of the things, again, about making facilities available: young men are not frequent attenders at GPs, for example, and unless they have had a need to go to a clinic, are they likely to necessarily know where their clinics are? They will know where things like pharmacies, etc, are so we need to think about the locations where people are going to be. We need to look and see as well whether we can run screening through colleges, for example, and other areas like that where a lot of young people may be gathered in the relevant age group at the same time and do things on a much wider scale.

  Q206 Dr Naysmith: I just wonder, as well, Minister about the concentration on under 25s, simply because there is a lot of anecdotal evidence—I do not know of any really hard evidence—that people are sexually active to a much later age.

  Miss Johnson: Considerably later than 25, probably.

  Q207 Dr Naysmith: We know that Chlamydia is sometimes used as an indicator of other potential hazards and risks being undergone. Is it wise to concentrate on the under 25s? I know it is because of the fertility aspect, but is it wise to concentrate on the under 25s and not have a general screening programme?

  Miss Johnson: I think that goes back to the question about the national campaign to a degree, and I agree; I think we need to extend the range that we are covering. It really does go up to about 30 though, the age groups that we are targeting through magazines and holiday-related publicity, pubs, clubs and all the rest of it. It has picked up up to the 30s. But the reason for targeting Chlamydia is because there has been a massive increase, because people are unlikely to know they have it, because about one in nine or ten sexually active young women is infected with it, and probably a similar number of men, and what we wanted to do was to actually raise awareness of it, so that people did not think "Chlamydia" was some unusual women's name. There was a degree of ignorance about it at one stage which meant that everybody had heard of gonorrhoea or syphilis or HIV/AIDS and not everybody apparently had heard of Chlamydia, and because there were not the symptoms, I think it was right and it is right to focus quite a lot of attention on it. But of course, if they come forward for testing on one thing, there is much more chance that if they have other, related needs, those needs are going to be identified and dealt with too.

  Q208 John Austin: I am just curious. Despite the recommendations in our report, your White Paper does not mention abortion services at all. Is there a reason for that?

  Miss Johnson: Our White Paper does not mention an awful lot of things actually. It was focused on the areas where we could principally change behaviour by a mixture of support, provision and education and information; an informed choice, as it were. There are obviously a whole lot of very difficult issues around abortion. There has been much discussion of it. It has always been a matter for Parliament to decide what happens with the abortion laws, and a lot of the provision around it. We have certainly concentrated a lot more money on contraception, which I think is the right area to put a lot of extra investment in. We decided to leave many things out of the White Paper. It would have been a huge document had we included everything that technically belongs to public health.

  Q209 John Austin: Abortion is clearly a key area within sexual health services. Will it feature in the implementation plan?

  Miss Johnson: No. The implementation plan is focused on what is in the White Paper, so it will focus on sexual health, where we have already made announcements, so everything from contraception through to the national campaign for clinics, screening and Chlamydia and so forth. As far as I am aware, we are not planning to have any provision or any particular reference to delivery on abortion in there. We have focused on improving early access to abortion and we have succeeded in improving early access to abortion. It is a matter of personal view but I personally think it would be much better if we succeeded a lot more on contraception.

  Q210 John Austin: Can I go on to a complete different area, charging for HIV services? There are many statements in the media, and I believe one of your colleagues in the Department has suggested that there is a high level of health tourism. In particular, there has been reference to HIV tourism, but I am not aware of any substantive research that has ever been carried out, and the evidence from organisations like Terrence Higgins that we have received would suggest that HIV tourism is a bit of a myth.

  Miss Johnson: It is very difficult to produce figures. Historically, figures have not been collected by the Health Service, over decades—never, basically—about levels of people using the service who are not resident or normally resident in the UK. That is partly because, obviously, some of the people who use those services are genuine tourists—and I am not just talking about HIV/AIDS here; I am talking more generally, because it is quite difficult, again, to make distinctions between this and a number of other things for which people need treatment. It is impossible therefore to disaggregate data as to whether a tourist came over and broke their foot and received treatment through an A&E department or whether somebody came in and received another service as a so-called health tourist.

  Q211 John Austin: The evidence seems to suggest that people who have come into the country with HIV actually seek treatment late, which seems to suggest they have not come here as HIV tourists.

  Miss Johnson: Yes. I do not want to join in your conjecturing. I do not have any figures to supply you with on this. I concur with the point that it is difficult to measure it, and we do not have reliable information. What we are clear about is that there was some abuse going on of the existing rules, and that is why the rules review was undertaken, and a tightening up of the wording to deliver the same consequences that the rules had almost all been intended to deliver before. There has been very little change of substance on the rules, but what there has been is a tightening up of the wording so that they actually deliver the results that they were originally intended to deliver when they were first devised.

  Q212 John Austin: I will come on to that in a moment, but you are really saying there is not any evidence that the UK is likely to become a magnet for HIV tourists?

  Miss Johnson: What is clear is that if people think they can come in and, under any circumstances, remain here for free treatment, we would become such a magnet, and that was what we were concerned to deal with. We are a national health service; we are not a global health service. We are here for people who are resident, and residency is the basis of the entitlement here, as defined normally by many of us here, permanently resident, but there are a number of other categories of people who count as ordinarily resident here for these purposes, and we have made sure that those categories are very clear in the revision that has taken place, because we did not want the wrong messages to go out elsewhere.

  Q213 John Austin: Let me come on to the rule changes and let us deal with the removal of the 12-month exemption. In the past, persons who have been here for 12 months, even if they no longer had proper authority to remain, were allowed treatment, and now that is not the case. That would include, of course, over-stayers and maybe failed asylum seekers, some of whom may well at some stage, through an appeal process, be regularised and be lawfully here. Has the Government any estimate of the numbers of people who are now no longer eligible for treatment as a result of the change in the 12-month exemption?

  Miss Johnson: No, we do not. Let me be clear about a few things, because I think it is very easy in this area for people to get the wrong end of the stick on it. First of all, people who come here are entitled to free tests and, under any circumstances, somebody here, as they are entitled to free sexual health services, they are entitled to free diagnostic tests, and the initial response to that in terms of counselling, free on the NHS, and that includes anybody who thinks that they have HIV/AIDS. So there would be no reason in relation to any of these things why somebody should not come forward early; in fact, what we need to do is increase awareness so people do come forward as early as possible for testing. But when people are coming into the country, there is a lot of evidence that people do get tested. What we are doing is making sure that, when they are here illegally, they are not entitled to remain simply to get free treatment when they are illegal over-stayers. That goes back to the earlier point, that the basis of treatment has always been residency, and that means legal residency, and people who have simply over-stayed, however long they have over-stayed, do not become legally resident by over-staying. We did not really change that, in a sense. We just went back to the fundamentals of it, that it is residency, and that means legal residency, and therefore, being here 12 months or more does not qualify you under those circumstances for free treatment. Can I just make one other point? There is still provision for easement by individual clinicians under individual circumstances, and at the end of the day, the decisions are the clinician's; they are not for ministers and they are not for politicians, or for any of the rest of us.

  Q214 Chairman: You do not have an estimate of the numbers affected by this change? Have you access to anybody else's estimate as to the numbers affected? Have no voluntary organisations put to you the numbers that are affected? You have no knowledge whatsoever, no guesstimates?

  Miss Johnson: No, no. Obviously, people who are being expelled are a matter for the Home Office as well, so that is not an issue for my Department.

  Q215 Chairman: I appreciate that, but you are in contact with other government departments, obviously, and in conjunction with them, there has been no estimate from them as to the numbers that might be affected?

  Miss Johnson: No.

  Q216 John Austin: I want to come on to this question of testing. I acknowledge that HIV testing is free of charge to anyone, and obviously we encourage that, and most of the organisations working in the field are engaged in encouraging people to come forward for testing. But Terrence Higgins have suggested to us that, where we are talking about migrant communities, who may not be eligible for access to treatment, there is now therefore a reluctance to come forward for testing, and Terrence Higgins in their evidence suggested this was having a significant impact on their encouraging campaigns.

  Miss Johnson: There obviously is a difference. The free bit of it is around the public health risk, and the public health risk if somebody has another sexually transmitted infection is that actually, if we treat them, that risk goes down to zero. Actually, treating somebody with HIV/AIDS, unfortunately, does not reduce their risk to the general population at all. It is only behaviour change that alters that risk.

  Q217 John Austin: But it is part of the Government's policy to reduce the number of undiagnosed HIV infections in the UK.

  Miss Johnson: Indeed, and we are actively trying to encourage people to come forward for diagnosis, because it is only upon diagnosis that people know that they need to change their behaviour definitively, and they can access treatment free, many categories of people, all those who fit the ordinary residency or who are applying for asylum whose applications are being considered. For those who are not legally resident here, obviously, there is not an ongoing entitlement to free treatment.

  Q218 John Austin: You are not concerned then about the evidence form Terrence Higgins that there is a resistance to come forward for testing where there is no eligibility for treatment?

  Miss Johnson: We do not have any figures that show that. In fact, what I think the figures indicate is that there are more people coming forward for testing and for diagnosis, and that probably, as well, the improved health outcomes for people with HIV/AIDS as a result of the improved drug treatments are leading people to think it is more worthwhile making sure that they get tested early and they get put on treatment as early as possible because that is improving their life chances, despite having the disease.

  Q219 John Austin: I might want to come back to that later. I understand that, in the correspondence between the Committee and your Department, the Department has made no assessment of the likely cost or cost savings of introducing the changes to charges for overseas visitors. Is that so?

  Miss Johnson: I have already explained that there are no figures about the numbers of overseas visitors being treated.

13   See footnote 1. Back

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