Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 240-258)


10 FEBRUARY 2005

  Q240 Mr Bradley: But would you want to ensure that using the overseas patient officer is applying the test of eligibility consistently across the country? From your position, would you want to ensure that each trust, through that . . .

  Miss Johnson: Yes.

  Q241 Mr Bradley: You would?

  Miss Johnson: Yes, but that is an application of the broad rules. You cannot argue about consistency in an easy way about individual clinician's decisions.

  Q242 Mr Bradley: Do you monitor those decisions from the centre?

  Miss Johnson: There are guidelines. There is a set of guidelines.

  Q243 Mr Bradley: Do you monitor how they are being implemented?

  Miss Johnson: There are obviously regular contacts. Elizabeth Ryan might want to comment on the contacts that are had between the Department and the managers, but clearly, there is regular contact between the Department and those involved with actually overseeing the implementation of the guidance.

  Ms Ryan: As the Minister has said, we have issued very comprehensive guidance, which has gone to every trust, and which we know through our contacts with overseas visitors and managers is followed fairly closely. I and my team have regular contact with overseas visitors managers. We attend meetings of the overseas visitors support group that Pam Ward co-chairs. We have people telephoning us, seeking advice and so on, every day, so we do know what people are doing and we do know that, if a particular issue is coming up, we can be in a position to make sure that people understand what the correct procedure is.

  Q244 Chairman: Would the kind of people ringing you be an individual GP or a PCT?

  Ms Ryan: It is usually overseas visitors managers themselves, the people who are actually operating the procedure, but yes, we have telephone conversations with members of the public, and I have spoken to one or two GPs, yes. We will talk to anyone who wants to seek advice from us.

  Q245 Dr Taylor: What bothers me, as an ex-clinician, is, with the clinical freedom, you start the treatment. Then the patient finds that they are one of the people who are not covered. Is there not a huge risk, when they discover the sort of bill they are footing, that they are going to just defect and not turn up and therefore stop treatment, and then they will be in an even worse state than before?

  Miss Johnson: I am sorry. The circumstances were not clear to me. You say that they suddenly find out. I am not sure what that amounts to.

  Q246 Dr Taylor: When the doctor starts them on treatment, does he say, because he has worked it out, "I am starting you on treatment but you are going to have to pay," or is that something that suddenly dawns on the patient later, so that when it dawns on them, they realise they are running up a huge bill that they can never ever afford, so they just stop the treatment and disappear, and then become another pool of infection?

  Miss Johnson: If they are seeing the doctor in the first place, the doctor has presumably become aware of what their residency entitlement is, as it were, and therefore whether they are entitled or not in the first place. You are not talking about somebody coming in through an A&E clinic here. You are talking about somebody turning up for a booked appointment. I am assuming that the doctor may well know what the circumstances of that particular patient are in any case.

  Ms Ryan: What would normally happen is that the patient will be told as soon as possible after first contact if they are likely to be chargeable. In an emergency, if somebody has turned up and they are clearly very ill and treatment needs to start straight away, then that treatment will happen, the treatment will start straight away, so there may be a day or two before it is possible to ascertain all the circumstances, to establish that they are chargeable, but you will not have somebody going weeks and weeks into treatment and running up a bill of thousands of pounds and then suddenly being told they have got to pay. That will not happen.

  Q247 Dr Taylor: No, because as soon as they are told, they will defect, so they will not build up that bill.

  Miss Johnson: One of the issues is, obviously, that some people do end up receiving charged treatment and are unable to pay, and so trusts do end up sometimes having to write off debts. That is not only in the HIV. We are only concentrating on this, but obviously these regulations cover a much wider area than HIV/AIDS. They cover the whole range of provision.

  Q248 John Austin: But with HIV, there is a major public health risk as well, which you, as a public health minister, must be concerned a bout.

  Miss Johnson: Of course, and that is why we want people to come forward for diagnosis, and that is why we are encouraging them to come forward for diagnosis, and that is why diagnosis is free. For many of the people that we are talking about the treatment is also free. The question that you are raising is whether there is a public health advantage to free treatment for those for whom free treatment is not being provided, and what I am saying to you is that it is not like some of the other things for which we provide treatment, where there is a course of treatment and you are cured.

  Q249 Dr Naysmith: We have evidence, Minister, that you will reduce the viral load by treatment, and that reduces infectivity, and that is known in HIV.

  Miss Johnson: Yes, "reduces" is the imperative word, I fear, but this is a debate that I am sure the Chief Medical Officer will be very happy to engage in with you.

  Q250 John Austin: The risk of transmission is very clearly linked to the viral load. The risk of transmission of infection is lower if the viral load is lower.

  Miss Johnson: My point is that it is not zero. Somebody who has had a course of treatment for gonorrhoea and taken the course has a zero risk.

  Q251 Chairman: We understand the point you are making. I am not sure everybody would agree with you, looking round the room. What I am interested in is, when we were looking at sex education—and we talked about this in the first part of this morning's session—I have a vivid memory of lots of evidence 18 months ago about the continuing impact of section 28 on teachers' views on what they could and could not say in the classroom, even though section 28 was withdrawn. Are you sure that clinicians understand exactly what they can and cannot do, or could we have an ongoing section 28-type situation, which could have serious public health consequences, because of a lack of clarity about what they can and cannot do, and a fear that what instinctively they want to do could have repercussions?

  Miss Johnson: I am sure it is possible to produce some examples of confused clinicians with 1.3 million staff in the NHS, of whom quite a lot are doctors. Some of them may not be fully abreast of everything about everything. I cannot say that you are not going to produce some examples like this, but we would be concerned if people generally had some kind of misunderstandings about this, that there were myths of some kind out there. We would, of course, be very concerned about that. That is one reason why the regulations were revised to end up with fundamentally exactly the same basis that they had always had prior to 2004, but they were tightened in a way that made it clearer exactly who was eligible and who was not. I think the main change, which we have talked about at some length, was the 12-month provision. It was never meant to cover those who had stayed illegally for 12 months; it was meant to cover those who were ordinarily resident; it was just that "ordinarily resident" had not been translated into "legally resident," and we just made it clear that that was always the intention of it. So the whole purpose of doing this—and there is a discussion going on currently about primary care in the same way, with consultation—was to consult in a widespread consultation over this. It took a considerable period of time, and Elizabeth may want to say all the organisations that were involved in that. We have done our best to make sure that there is buy-in understanding and that this does clarify the situation considerably. That is not to say you will not find an example out there of somebody who does not understand.

  Q252 Chairman: As far as Ms Ryan is concerned—and you mentioned earlier on that you do have contact with trust charging officers—you would feel that the Department has taken as many steps as it can do to ensure that the people who are in the front line, the clinicians who will meet the patients, fully understand what these regulations mean, and from a public health perspective, do not feel constrained?

  Ms Ryan: Yes, I am very confident of that. The guidance is very clear that clinical priority comes first.

  Q253 Dr Taylor: I am going on exploring that, because what we are missing is an actual clinician on that handle. If I can just pass on a comment that has been passed to me, it has been said by one of our experts that, because of the anonymity and the confidentiality and the open access of these sort of clinics, the doctors do not know every issue at the time when they have to start the treatment, and they are not really able to work it out, and there is no standard way that these people are assessed in clinics in practice, therefore people are being started on the treatment before they are aware at all of the costs, and so there is a huge risk of drop-out.

  Miss Johnson: There is no reason why those who are managing the clinic should not be having a regular dialogue with the overseas visitors managers. If they are not doing so, obviously, they will necessarily be short of understanding and guidance, but there is no reason why that should not be taking place, and I am sure that the overseas visitors managers stand very ready to have a chat, either with clinics or with individual clinicians, whatever. As you know, people do not just turn up and get immediately put on a script for HIV/AIDS treatment, so it is not just going to happen overnight.

  Dr Taylor: I can see a recommendation coming!

  Q254 Dr Naysmith: Minister, this whole area has all sorts of potential ethical dilemmas between doctors and patients, and doctors and their employers, given what we have just been talking about, and doctors having the freedom to start a treatment, and then maybe a PCT deciding that they do not have enough money for it to continue, or whatever reason. We know from evidence that was given to us that doctors do not like this kind of gatekeeper role in this area. Have you had any discussions with the GMC about the implementation of this policy and what it means for the professionals who have to take these decisions?

  Miss Johnson: Elizabeth may want to comment. It was before my time in the Department that a lot of the discussions were going on, and I am not the Minister who deals with this on a day-to-day basis either. What I would say is that people have had plenty of opportunity to be involved with the consultation. We did discuss the question of easement for clinical decision-making, and that easement was built into the new guidance that was issued. When you say people running out of money, I am not quite sure what you mean. I do not think people run out of money.

  Q255 Dr Naysmith: I did not say "running out of money".

  Miss Johnson: I thought you did.

  Q256 Dr Naysmith: I am sure the transcript will show. There are two primary care trusts in my area. Somebody in my constituency moved from one to the other recently, and they were receiving a treatment paid for by one, and when they moved into the next one, they were told they could not have it, until I intervened. There is room for that kind of misunderstanding in this area, particular since I suspect in some parts of the country all PCTs do not have overseas visitors managers.

  Miss Johnson: Overseas visitors managers. All the trusts do.

  Q257 Dr Naysmith: I am sure they do, but in some places they will get a lot to do and in other places they will not get very much to do, and it is that kind of area where you can get problems arising because they just read a circular and think "This is what we do."

  Miss Johnson: I am sure their association also provides support and guidance as well, and I know that you had the opportunity of taking evidence from Pam Ward.

  Q258 Dr Naysmith: We are quoting experts, and one of our experts passed me something that I should have known when I was talking about virus load. Basic epidemiology says quite clearly that you do not have to reduce a risk to zero; you only have to reduce it to less than one. Our experts win!

  Miss Johnson: I note that. I think we shall have to get the experts to do battle. I nonetheless maintain the very firm understanding, which is that there is a zero risk for some things after treatment and there is not a zero risk with HIV/AIDS.

  Dr Naysmith: I should have known that because of a basic immunology course I did many years ago. That was something I should have known.

  Chairman: Minister, can I thank you and your colleagues for a very useful session. We are most grateful to you.

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