House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

NEW DEVELOPMENTS IN HIV/AIDS AND SEXUAL HEALTH POLICY

 

 

Thursday 27 January 2005

PROFESSOR GEORGE KINGHORN, MS ANNE WEYMAN

and DR WILLIAM FORD‑YOUNG

MS LISA POWER, DR MAX SESAY and MS DEBORAH JACK

DR DAVID ASBOE, DR BARRY EVANS, MS PAM WARD and MR PETER NIEUWETS

Evidence heard in Public Questions 1 - 121

 

 

USE OF THE TRANSCRIPT

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Oral Evidence

Taken before the Health Committee

on Thursday 27 January 2005

Members present

Mr David Hinchliffe, in the Chair

Mr Keith Bradley

Mr Simon Burns

Dr Doug Naysmith

Dr Richard Taylor

________________

Memoranda submitted by Professor George Kinghorn and the FPA

 

Examination of Witnesses

 

Witnesses: Professor George Kinghorn, Consultant in Genito-urinary Medicine and Clinical Director for Communicable Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Ms Anne Weyman, Chief Executive, Family Planning Association, and Dr William Ford‑Young, general practitioner, Broken Cross Surgery, Macclesfield, examined.

Q1 Chairman: Good morning, and may I welcome our witnesses. We are pleased to see at least two of you before the Committee once again. As you know, this part of this morning's session particularly is, in a sense, an update on developments since the publication of our report on sexual health two years ago. Obviously we are aware of a number of developments. I think you appreciate that we are taking evidence later this morning on one aspect of an area that we looked at during our inquiry. I wonder if we could start by particularly asking you, Professor Kinghorn, for your views on developments since 2002, trends on STIs, on HIV, since we reported and what has been happening, in your view, with regard to how quickly people can be seen at genito-urinary clinics. As you know, we expressed a very serious concern over the delays in people accessing treatment in various parts of the country.

Professor Kinghorn: We are delighted that the public health importance of STIs has been recognised, that they have been given additional priority and that there are new resources to support service expansion and meet patient demand for services. We are especially pleased that the recommendations of this Committee have been acknowledged in this way. We are very grateful for your influence and support. In talking about the changes that have occurred over the last two or three years, generally there have been accelerated pressures on clinic services. In my own city of Sheffield, our new patient episodes of care have increased by 30 per cent. We have had a doubling of diseases such as gonorrhoea and syphilis and our number of new cases of HIV on an annual basis has trebled.

Q2 Chairman: Before you go further, could I ask you for your thinking on the reasons why more people are coming forward. You say that there is more incidence, or is it that people are more aware of the means of accessing help? Are there other factors that may have a bearing on the increased presentation of people at your clinic?

Professor Kinghorn: I think there is very definitely a worsening, an increase, in the incidence of sexually transmitted diseases, as evidenced by the cases of gonorrhoea and syphilis that we are seeing. These are new problems. Although some additional resources have gone into clinics, the amount of resource that went in was less than that recommended when we met with you previously. There is a widening gap between the patient demand and our clinic capacity and, sadly, I think that is going to get worse. It is true that there is increased knowledge about the risk of sexually transmitted diseases, and I am glad to see that more people are attending for check-ups to assure themselves that they are healthy before they change partners, but all of that just tends to increase the pressures on services. Unless we do something to increase capacity, both in the clinics and in other community settings, then I think that gap is going to stay wide.

Q3 Chairman: You recall that one of the issues we raised was this question of a 48-hour access target, which is picked up, of course, with the White Paper. In listening to what you have just described are the problems now, what is going to need to be done to increase capacity to meet the target that the Government has set?

Professor Kinghorn: I think the target is welcome but it is very challenging for us to achieve by 2008. Despite extensive modernisation of our clinical practice to increase the throughput of new patients, as I have indicated, there is still this very wide gap between capacity and demand. In order to achieve the 48-hour target, there is a need for resource at least to increase the clinic capacity that is to meet that gap but also the additional workload that will inevitably result from an education campaign. We also need to increase capacity in community settings. There needs to be additional provision of services, contraception services in primary care, and it is essential that there should be increased training opportunities for practitioners in those settings. I think that that will require a separate training budget to be established. In the specialist services, we do have an additional problem of space. I could acquire the people but I need to provide those services, and I would have great difficulty in providing the space for them to work in the most effective way. So I hope that the GUM review which is being carried out will help us to show where those resources need to be put so that we can increase space as well as the capacity in terms of seeing patients.

Q4 Chairman: Your comments obviously relate to your experience in Sheffield. Do you feel that the picture you have given us applies across the country as well as just in your part of the world?

Professor Kinghorn: Yes, I think the evidence is that there is a problem throughout England, but we do know that when we look at trends in sexually transmitted infections, there are worse problems in north and eastern England than perhaps there are in London, but it does tend to appear that the worst problem, in terms of increased incidence of disease, occurs in those locations where clinic access is worse. So poor access tends to lead to more problems.

Q5 Chairman: Is this anecdotal or can you give hard circumstances?

Professor Kinghorn: There is evidence.

Q6 Chairman: Can you point us in that direction?

Professor Kinghorn: There is evidence from the Health Protection Agency both in terms of waiting times, the order in which they have performed, and in terms of their original data for 2002-2003.

Q7 Chairman: What you are saying is that if there are more awareness campaigns in terms of prevention that will result in more people presenting themselves to GUM clinics? I recall when we were in Manchester one or two of us making suggestions about preventative campaigns and the people in the GUM clinic there put their hands up and said, "No, we could not cope with the additional demand that would arise from what you are proposing". That is a picture that applies across the country presumably, a concern that the more the awareness, the more the demand and the more difficulty in meeting the capacity?

Professor Kinghorn: Yes. We are in a bit of a dilemma. I wish to encourage people to take responsibility. I wish to encourage people to take that personal responsibility for their health and for the health of their partners, but, unless capacity increases go hand-in-hand with the education campaign, then there is a risk that services which are under severe pressure would be in a state of collapse. The concern we have at this present time is that new resources for capacity may not become available until 2006-07, which will be after the education campaign has been proposed. That, in our view, would lead to a great dissatisfaction amongst the public because we could not cater for the obviously increase in demand.

Q8 Mr Burns: Do you have collective statistics or do you have any evidence that when someone goes to a clinic and they find that they have to wait possibly four, five, six, 10 or 12 days before actually seeing someone then they fail ever to turn up again?

Professor Kinghorn: Yes, there is a proportion of patients who will not come. This is particularly the case with the young. There is a window of opportunity and it is important that when individuals present they should be seen at that time, otherwise there is a risk that they will not turn up and they will continue to ignore symptoms.

Q9 Mr Burns: Do you think it is more that they will continue to ignore symptoms rather than that they will try and get help elsewhere, like going to their GP or whatever, or to another clinic, depending on where they live?

Professor Kinghorn: Some will try to go to other settings, but I think many will fail to turn up.

Q10 Dr Taylor: May I go back to the 48-hour targets for the moment? We gained the impression with the GP 48-hour target that some practices actually suspended the list at 48 hours so that nobody was over it. Is there any evidence that you are doing the same sort of thing, or have you managed to avoid that?

Professor Kinghorn: This is an issue about which I feel particularly strongly. The 48-hour access should be from the time that the person first makes contact with that service. It is not acceptable to me that they should be required to ring up on succeeding days.

Q11 Dr Taylor: They should ring up every morning at 8.30?

Professor Kinghorn: I think that is quite an iniquitous system and should be strongly discouraged. I think what we are saying is that we wish to have 48-hour access, if not immediately, from the time that the person first makes contact.

Q12 Dr Taylor: Going on to funding, you have already said you welcome the new money but that the resource is rather less than recommended. What we want to explore is whether it is actually getting through to you. In the brief, the British Association said that 90 per cent of the £5 million that was allocated directly to GUM clinics got through, but not all of the rest that went to PCTs, and in fact it is so bad that approximately 50 per cent of the money only reached its intended destination. What is the answer to this?

Professor Kinghorn: If I may give some further explanation to this, in 2003-04 there were two allocations. The first was £8 million of recurrent funding; the second was £5 million of non-recurring funding. Both of these allocations were made to PCTs rather than directly to clinics and only half of all of the clinics recorded receiving their full allocation, and one-third of the total funding in 2003-04 appears to have been used for other purposes. In my own city of Sheffield half of the recurrent amount in 2003-04 was withheld by the PCT, and their reason was that sexual health and GUM services were not seen as a priority. I think the answer is that we now have increased priority as a result of the White Paper. As ever the optimist, I hope that there will not be a repeat of this in the future. I think that the other answer which is very important is that there should be strong performance monitoring by strategic health authorities to make sure that this cannot happen again.

Q13 Dr Taylor: They should be monitoring that the money actually gets where it is intended to go?

Professor Kinghorn: Yes.

Q14 Dr Taylor: If you get all that is proposed, will that enable you to meet the 48-hour target, for example?

Professor Kinghorn: I can only say that I hope so. I think that with the potential capacity requirement, if we encourage everyone who changes their sexual partner to seek a check-up before they have a relationship with a new partner, we are talking about a demand for services which is hugely increased from that which is met by GUM services at the present time. We are talking here of potentially millions more patient episodes. I am optimistic that we can do more, but I think we will just have to see how things develop. I know that within my own setting we are planning for there to be a 50 per cent increase in new patient episodes within the next three years. I know that we need to increase community capacity by two or three times if we are to meet the demands which are going to be placed upon us, but I am ever optimistic.

Q15 Chairman: Could I clarify that I understood you correctly to say that when people change their sexual partners they should have a medical check?

Professor Kinghorn: Yes.

Q16 Chairman: And people who change their partners several times a night could cause some difficulties, presumably?

Professor Kinghorn: They will need to be seen more frequently!

Q17 Dr Taylor: I am wrestling with the recommendation we have to make because strategic health authorities have only one aim, and that is to balance their books. If the PCT does not have enough money even to meet its stated targets, we are going to have to wrestle with this one. I think we have the message.

Professor Kinghorn: I think we also see a role for the Healthcare Commission in making sure that they are supporting sexual health and that they do have an increased role in the future in ensuring that the services are appropriate to meet local need.

Dr Taylor: That is a very good point and it is something we can stress to the Healthcare Commission.

Q18 Mr Bradley: The White Paper also announced the introduction of chlamydia screening throughout England by 2007, with particular emphasis on women under 25. First do you have any general comments about that aspiration? Secondly, could you update us on the availability of the NAATS screening testing in England?

Professor Kinghorn: We are very glad that the availability of the most sensitive tests will occur throughout England by 2007. Currently, about 25 per cent of the country has access to the most sensitive test. I am concerned to ensure that the most sensitive tests are used for all people, irrespective of their age, and not just reserved for those women under the age of 25. Of course, a screening programme based on opportunistic screening of young women alone has its drawbacks when the prevalence of infection in young women is about one in ten of those sexually active women under the age of 25. The prevalence in young men under the age of 25 is also about one in ten, or more. It is important that we should be encouraging young men, as well as young women, to be screened.

Q19 Mr Bradley: So I am clear, you are saying there is 25 per cent access to the NAATS test now?

Professor Kinghorn: Yes.

Q20 Mr Bradley: By 2007 what percentage do you think will be available for that?

Professor Kinghorn: I am assured that the programme is that all areas of the country will have access to the most sensitive tests, but the availability of such tests in all areas may not necessarily be the same thing as access of all patients to the most sensitive tests. It is important that diagnostic services should be equally available for all who need them.

Q21 Mr Bradley: But you do not believe that will happen by 2007 for all categories?

Professor Kinghorn: I hope that it is going to be available by 2007, but I think there may well be difficulties in achieving that date.

Q22 Dr Naysmith: Could I bring in Dr Ford-Young now and talk a little bit about primary care services as they have been mentioned. In 2001, the Sexual Health and HIV Strategy envisaged a crucial role for primary care in this area. As we understand it, the new GMS contract does not offer much in the way of incentives to do that, so do you think there has been a missed opportunity? Perhaps you could help us understand the issues surrounding that and why there are not incentives?

Dr Ford-Young: I think there has been a great missed opportunity in our new GMS contract. GPs who have an interest in sexual health, like myself and my colleagues, very much welcomed your report in June 2003, and you recognised the potential that general practice and other parts of primary care have in delivering good quality sexual health services. We see a lot of patients through our doors. We provide up to 80 per cent of contraception services in England and, in a way, we are the sleeping giant of sexual health services. Your Committee and we ourselves were optimistic that our new contract would help improve the provision of quality of care for sexual health but, unfortunately, it does not. It appears to have ignored the National Strategy for Sexual Health and HIV.

Q23 Dr Naysmith: Why do you think that is?

Dr Ford-Young: I think it has ignored the levels of care that exist within the National Strategy for Sexual Health. Basically, we have a three tier contract. The most basic level is what is termed essential services. That is for us to react to patients who walk through our doors who are ill, or believe themselves to be ill; to provide management for chronic disease; and to provide terminal care. Within that, I think I, as a general practitioner with an interest in sexual health, would include sexual health as part of general medical services because sexual health is part of our health and wellbeing as human beings. I think, however, the negotiators who negotiated the contract felt that sexual health was not part of essential services. Whilst the national strategy provided holistic levels of care for all the various parts of sexual health from contraception to STIs and cervical cytology, et cetera, our contract decided to place these various elements of sexual health into various additional add-on bits of our contract over and above essential services. The only part of our contract that really encompasses sexually-transmitted infections is what is called the National Enhanced Service, which is very much a high level, add-on bit of the contract. There would be very few practitioners in the country who would have all the skills and competencies to provide that service. In my experience, there are very few PCTs that are commissioning that kind of service.

Q24 Dr Naysmith: Would it enable some practices to specialise in this sort of area of medicine for a particular part of a city or something? The system is there but you are saying you think it is unlikely to happen?

Dr Ford-Young: That is possible. It is happening in some areas but there is a reluctance, I think, by many PCTs because of what they see as financial constraints and where they see the importance of sexual health on their agenda to decide to commission such services. We lack any formal national training programme to upskill general practitioners and their nurses, and so on, to provide these services. We need to include general practice as a good site for chlamydia screening, but screening is not seen as an essential service, so again that needs to be supported and resourced. I am aware that the Department of Health is looking at a model whereby it could be formed as an enhanced service into general practice, but that does need the commitment from the Secretary of State to provide the resource to do that. We need to look at the competencies involved for that, and so it is not going to happen overnight.

Q25 Dr Naysmith: In a kind of anecdotal way, how do your colleagues feel about this? Would they like to get more involved in it if there were more incentives? When we were doing this last time round, we all agreed that we, as Members of Parliament, hardly ever got any complaints about sexual health services. We get complaints from constituents about all sorts of other things but rarely about sexual health services. I wondered if the same kind of thing applies amongst professionals. Is it low down on the horizon?

Dr Ford-Young: I think people's perception covers a wide range and where they themselves as general practitioners would put sexual health on their agenda. Generally speaking, certainly anecdotally from my area where I have been involved in trying to roll out a chlamydia screening programme at a phase two site, of my colleagues who unlike myself do not champion health but feel that chlamydia is an important cause, over 50 per cent in my area wish to be involved in the chlamydia screening but see the contract as getting in the way of being able to find the resource in time to provide that service.

Q26 Chairman: Could I ask you about an issue that obviously struck us all when we looked at sexual health two years ago and it was that as MPs I do not think any of us had received any representations from constituents about problems with GUM services or accessing services. At that point, I think all of us saw a dilemma. In the process of moving decision‑making on health care more and more towards local people through PCTs and decision-making in the secondary sector as well to local people, that same problem of us being unaware of what was happening would be shunted to local decision-makers from national decision-makers. How do we get an awareness of the kinds of problems we are talking about here today across to those people who are making the decisions that result in Professor Kinghorn only getting a small part of they money he ought to be getting? Do you understand the problem I am describing? Money is a difficulty which we felt, as a committee, was hard to challenge and how you got this awareness across that enabled you then to direct the resources where they were needed.

Dr Ford-Young: One of the things we probably need to look at and support, and again it does need support from the centre, is managed clinical networks. When we lost health authorities and moved to PCTs and we were shifting the balance of power, we actually lost a lot of expertise and competence around commissioning sexual health services, especially some of the more specialised sexual health services like HIV treatment and care. I feel a PCT is too small a body to be commissioning at that level because the more specialist services lie across several PCTs. In the implementation plan of the national strategy it suggests that we should be looking at more joined-up commissioning of primary care organisations working together. There is a good example, I think, of a managed clinical network in Greater Manchester, which covers the strategic health authority area whereby I think a lot of the problems we had with shifting the balance of power can be addressed, still at local level, without everything coming from the centre nationally. A managed clinical network like that helps to link the various service providers from a GUM clinic to an HIV provider to a general practice or a community family planning clinic or a voluntary organisation. It can help to have all those service providers providing a basic minimum standard of care, which would be a good standard of care to ensure patient care pathways exist. All too often we forget that the patients should be at the centre of our care in our pathways rather than developing our services to suit ourselves. I think they will be the drivers in the clinical governance issues to ensure good value for money in those areas and to ensure that patients actually get the choice and the service they need and deserve.

Q27 Dr Taylor: Can I go on and explore that a bit further because managed clinical networks are thrown up as the answer to so many of the specialties in difficulty. How does Manchester actually work? Could you give us some detail? Are there any other managed clinical networks that are co-terminus with strategic health authorities? For cancer, cancer networks are not co-terminus with strategic health authorities, and that always seems to me to be a bit odd.

Dr Ford-Young: I do not think necessarily a managed sexual health network needs to be co‑terminus with an SHA but I think that is useful because of the SHA's hopefully increasing involvement in quality and performance management, perhaps with the extension of local delivery plans at PCT level. This is something else and I think a managed network can help co‑ordinate PCTs to incorporate sexual health in their local delivery plans so that sexual health does get on the agenda at PCTs.

Q28 Dr Taylor: So a network should really be just a central unit with the consultant travelling out to outreach clinics and involving the GP specialists as well?

Dr Ford-Young: I do not think you necessarily need to have the consultants travelling out. I think the network allows people to stay where they are in their service providing their service, but the network helps to co-ordinate those different elements of care. I think the important thing is that it is a managed network and that resource is found actually to manage it, so that we do not rely on people's goodwill to come to a meeting at lunch time from their work to try to get round a table, but that there is a facilitated network.

Q29 Dr Taylor: Going back to the GP specialists, because again in geriatrics and in palliative care GP specialists are seen as the answer until there will not be any poor GPs left. How many GP specialists in sexual health are there? Have you any idea?

Dr Ford-Young: I do not actually know, and I am not certain that the Department of Health's Sexual Health team knows either.

Q30 Dr Taylor: It is probably very few?

Dr Ford-Young: I think there are very few who are actually employed as GPs with a specialist interest in sexual health. There are also GPs like myself who have an interest, but we are not actually classified as GPs with a specialist interest and contracted as such.

Q31 Dr Taylor: So there is a difference?

Dr Ford-Young: There is a difference, yes.

Q32 Dr Taylor: You have already hinted that there is not much training. What would be the ideal way of training and attracting more GPs to take on this?

Dr Ford-Young: I think we very much need to look at driving and funding a nationally‑agreed training programme organised through professional bodies such as the Royal College of General Practitioners, the Royal College of Physicians and the Faculty of Family Planning, for example, because we need to be looking at sexual health holistically. A very good model was developed around the management of substance misuse in general practice because there was the will by Government to fund that and the will of the Royal College of GPs to take that on board and develop a course. I think a similar model would work well for sexual health in that managing sexual health, like managing substance misuse, is often seen by many as a not very nice thing to be dealing with, and a client group of people may have some problems in dealing with it, too. I think that has very much helped to normalise the care of people who have substance misuse. One of the most important things we need to do with our care is to normalise talking about sex and sexual health in all care settings, but particularly in general practice.

Q33 Chairman: What drove you to specialise in this area? If you were in Manchester or London or wherever I could understand, but Macclesfield? Sir Nicholas Winterton is a very good friend of mine but I do not get the impression there is a great deal of sex going on in Macclesfield!

Dr Ford-Young: I can assure you there is a lot of sex going on in Macclesfield, regardless of whether Sir Nicholas is our MP or not! He is a good friend of mine as well. I have always had an interest in sexual health and I have always worked part-time in GUM clinics as well. In fact, I work in one in Withington, as well as the one in Macclesfield, as well as being a GP. I am fairly unusual in that. A lot of my GP colleagues, whilst they do not wish to work in a GUM clinic as well as in general practice, still have a firm desire to provide good quality sexual health care holistically to our patients because we are generalists and are finding it very difficult to be rewarded to do that. Also, PCTs do not have any sticks to beat us with if we do not come up with the goods, so we have no carrots or sticks basically in sexual health in general practice.

Q34 Mr Burns: Professor Weyman ---

Ms Weyman: May I say that I am not a professor. I do not know how that crept in and I am very flattered.

Q35 Mr Burns: You obviously are not a politician because, if you were, you would not have admitted to that! As you are aware, the White Paper has announced an audit of contraceptive services during the course of this year. Would you like to share with the Committee your observations on that, and also the scope and the quality of the services currently provided across the board?

Ms Weyman: We greatly welcome the fact that there is going to be this audit of contraceptive services. We feel that contraception has been very much the neglected area of sexual health for a long time. Just as we have heard all the problems that there are around GUM clinics, the problems around contraceptive clinics are many: the lack of resources; problems of premises; problems about having insufficient staff to run them. There is a huge number of problems. We do very much welcome this audit but we think it must be something that really is quite comprehensive. As Dr Ford-Young has said, a great deal of contraceptive advice is provided in general practice in England, and so the audit must look at what is going on in general practice as well as looking at what is going on in community clinics and take that comprehensive view. As I say, we are aware of the variability in the quality of services, not only those from general practice but also within community clinics as well. There is a question about looking at how the full range of contraceptive methods is provided so that there is proper access to the full range, which is patchy in many areas. This is partly a question of the skills and capacity of professionals but also about the funding that they have access to in order to provide particularly the longer-acting methods, which in the short term are more expensive. So this is a really important review. We do very much welcome that it is happening.

Q36 Mr Burns: Do you have high hopes for the outcome of it?

Ms Weyman: The review is the start, is it not, and it is really about what happens after that and how we go about improving the services that are available. I think there is a great deal of work to do there both in terms of the investment that is required - and we have a certain amount of money set aside for that but we do not know until we have done the review whether the amount of money is in any way going to match up to what is needed to be done - and also in terms of looking at who the professionals are who are going to provide the service, the doctors and nurses who would be involved, and how they are going to be trained. One of the problems at the moment about attracting people in to work in community clinics is the way they are paid compared with other areas of health care. There is a whole range of questions that needs to be looked at to ensure that we have the physical capacity in terms of places but also the people who can provide that services as well.

Q37 Mr Burns: If we can move on to the actual services, as you are aware, since the publication of the Sexual Health Strategy, there has been a number of initiatives set up to evaluate an integrated sexual health service bringing together GUMs and family planning services. How is that progressing, to your mind? Do you have any general comments on the initiatives so far?

Ms Weyman: I think this whole question of how you look at sexual health and sexual health services together is still a very big and an unresolved one. If you look at the way the White Paper is constructed and the way the funding is constructed, it is all constructed in terms of individual services rather than thinking about the experience of the person who is coming along to make use of those services. So I think there is a conceptual level which has not really been taken on. The managed network is already talking about the management of something, but you need a strategy that is going to take account of all these different aspects and be working out how they work together. Integration of specific services is one thing; but the integration of how you think about sexual health as a whole and how you plan it and how the budgets are structured is another thing, which in many areas is not on the agenda. Some of those divisions are quite interesting. If you look at it in most areas, for example the budgets and the commissioning of services for contraception and abortion are separate. They really ought to be brought more closely together. There should be more integration between those aspects of the services as well as discussions about the relationship between GUM and contraception. In terms of some of the things that Professor Kinghorn was talking about, such as testing for STIs in other settings, unless you get those services up to standard, those settings will not be there either. There are lots of different issues about making sure that you are thinking about it as a whole so that the various elements are of a sufficient level and capacity for you to think about service delivery in a more related way as well.

Q38 Dr Naysmith: I wanted to ask Anne Weyman very quickly - and I know Simon Burns said she was not a politician but this is a slightly political question - what she thinks is the driver for the White Paper to announce the audit of contraceptive services? What is the background to it? Is it perceived as really something wrong that has to be put right or is it a reaction so that we remember that a few years back we were all talking about taking clinics out of the community and giving them to GPs? This may be an opportunity to switch over. Do you think at last that concern has got through or is it for some other reason, or have you just been beating the drum?

Ms Weyman: I hope it is because, first of all, in your own Committee's report you highlighted problems around contraception, the concept of services and the difficulties. It is something we too have been talking about for a long time. Again, one hopes that the message has come through. In this area as well people do not come forward and complain about the quality of the contraceptive services that they are getting. Often I do not think that women have the knowledge that they are being denied methods of contraception; they do not know that all these methods exist because nobody is telling them about them. I do think that a lot of that has come from the pressure that we collectively have been putting on to have the services looked at and the needs that there are. I think there is also recognition of the problem. If you look at the relationship between conceptions and abortions in different parts of the country, there are very great variations, and in many ways that gives some indication, I would say, that contraceptive services are not always meeting the needs, because quite clearly they are not preventing as many unwanted pregnancies as they could be. If one is looking at the way the best compare with those with the worst records, you can always see considerable room for improvement.

Q39 Chairman: Anne Weyman mentioned a few moments ago the link between abortion and contraceptive services. You will recall that in our previous report we made some recommendations regarding abortion provision, none of which has progressed into the White Paper. I wonder what your thoughts are on this and the implications of the Government not perhaps picking up the concerns we expressed.

Ms Weyman: We were disappointed that abortion was not mentioned in the White Paper because there are many issues, as you highlighted in your report. There has been some progress in relationship to the provision and access of abortion services over the last few years with the under 10-week abortions being within the balanced scorecard for PCTs, and with some central investment going to PCTs to help them improve, but there is still a huge variation. If you look at questions around access, there are two measures that you can use: one is the difference between those women who get their abortions before 10 weeks, and in the 2002 figures the variation was between 9 per cent and 79 per cent at the top and bottom of the range, and the numbers that are funded by the NHS, which is another measure of access, and the variation was between 46 per cent and 97 per cent. So we are still seeing huge variations in these measures of access. There is a great deal more to do. We do not have detailed PCT figures for 2003; they have not been published. We know that in many areas there are still long waiting times and that there is a lack of choice of method, lack of availability of the early methods for medical and early surgical abortions as well. There still is an enormous amount to do. Another particular area is access for abortions at later gestations where in some areas it is almost impossible for women to get their legal entitlement. We receive quite a lot of calls on our help line from women who have been told they are too late when they have come perhaps at 12, 13 or 14 weeks. There are still many areas to be addressed. We hope that in the implementation plan for the White Paper these will be picked up alongside the other issues that have already been mentioned in the White Paper.

Q40 Chairman: Would it be fair to say from this short session that the impression, particularly from Professor Kinghorn's evidence, is that we still have what we term a crisis in sexual health? If that is the case, what further steps can we take perhaps to press for what I think to us was the most obvious step forward, which was the issue of sex education? The message we got loud and clear, whatever our views as a committee, was that where there is good quality sex education, despite the views of some, that tended to delay the onset of sexual activity and people were more aware of the implications. We made recommendations about the National Curriculum and sex education at a younger age which, sadly, have not been picked up by the Government. What do you think we can do to press this issue further, bearing in mind the serious state of the services that you and Professor Kinghorn have described?

Professor Kinghorn: There is a continuing crisis and in some respects the situation is worse, as I was trying to indicate, than it was in 2001. We have an opportunity, and we are very grateful for that opportunity, to address the problem. Education is important at all levels, not just for young people. It needs to start with young people but it needs to be continued and it needs to be seen to be applicable to all of us, whatever our age. It also needs to be sustained. The danger has been in the past that education campaigns have come and they have gone. Unless it is sustained and there is seen to be a commitment for the future, then it will only have a temporary effect. It is important that education and service provision should go hand in hand, that we should not fail to meet the expectations of our public. If we have stimulated them to looking after their health in a better way, we have to be ready to provide the services that they require. We need to be able to extend services within not only my setting within secondary care but also in primary care. There is a huge need, as Dr Ford-Young was explaining, for training within general practice and developing potential providers. It is important that it should be co-ordinated and we should not see it as either being one or the other. There has to be this combined attack on the problem.

Ms Weyman: If I may say something about sex education, this week we have had the report from the Chief Inspector of Schools about personal, social and health education and sex relationships education, which was damning about what is going on in schools. I do not think there has been very much progress since your report. Although the Department of Education says that it is committed and then there is guidance for schools, it is quite clearly not happening. I think we have to go on making the demands for sex and relationships education to become a broad programme, not the small amount of sex education that is currently compulsory but that we have this within the National Curriculum from an early age. I think it would be very valuable if your Committee continued to press for it, otherwise we are failing in providing young people with their entitlement to appropriate education and the capacity that that can provide for them to protect their sexual health and make responsible decisions about what they do to protect themselves and their partners. I think this is an area which needs constant pressure and that the Government's response has not been strong enough.

Q41 Dr Naysmith: Dr Ford-Young, you were nodding vigorously when education was mentioned. In our previous report we came across at least a couple of instances in this country, and two or three in other countries, of general practitioners, primary care professionals, going into schools in a kind of very informal way, a drop-in way, and students could drop in. I wondered, given the previous discussion about the lack of incentives and so on, how we could try to make that happen more widely in various communities around schools, as well as what the Chairman was asking for.

Dr Ford-Young: I would certainly echo what my two colleagues have said about the importance of relationships and education on sexual health taking place in education. As a general practitioner, I have an advantage in that when I see a patient I can provide some education, but that is all too often too late because they may be presenting me with a problem and we have missed the boat. That has to take place in education and not be left to health. I have mixed feelings about professionals like myself going into schools to deliver education. I do that for our local high school, and it goes down well with them. Apparently I can say things that the teachers or other people cannot say. I think it is a great shame that I can and they cannot say things. However, I am not trained as a teacher or an educator, and I think that needs to be looked at. I am here as a general practitioner and if I go into a school I am there as a GP not as a teacher or an educator.

Q42 Dr Taylor: Can I go back to raising the profile, which we have all agreed is absolutely essential, particularly with strategic health authorities and PCTs, because the alarming rate of increase alone has not been enough to do it? Who should be the champion at PCT level? Should it be the public health lead; should it be the specific PCT lead for sexual health, if there is one; or should it be consultants in infectious diseases or GUM? Where should the push come at PCT level to make them get it into their local delivery plan as a high priority?

Dr Ford-Young: Speaking from experience as a sexual health lead for our PCT and having met other ones around the country, I think the lead needs to come not actually at PCT level but probably at strategic health authority level to ensure that PCTs do incorporate sexual health messages and lines into their local delivery plans. I think one of the biggest drivers we have, and maybe in a way this is the thin end of a wedge around sexual health, is about chlamydia and chlamydia screening. I understand that LDPs are now going to have a line in on chlamydia screening. I think chlamydia screening is a good opportunity for us to improve our approach to sexual health because it is the commonest STI we have; it affects young people; and the screening can be delivered in a whole variety of health care and non-health care settings. For a PCT, that is a great line to have in their LDP. I would call it the thin end of the wedge because it can then help us to talk about sex in the generalist setting, which we have difficulty doing, and we have difficulty with our skills. That then means we should then be able to start talking about other STIs, other risk-taking behaviour, and we could start maybe to normalise talking about HIV and HIV testing in general practice, which we know we need to do but there is great reticence in the profession to do that. I think the way in and the way forward is through chlamydia screening with local delivery plans and PCTs actually being performance-managed on the uptake of chlamydia screening.

Ms Weyman: I want to make a comment about what has been happening in London. I think there have been very interesting developments in the strategic health authorities in London. The five chief executives of the strategic health authorities decided that they would make sexual health an area that they wanted to look at in greater depth. They set up a steering group to develop a strategy for London, with certain levels of performance that they wanted to see. That has now been adopted across London. The strategic health authorities are discussing with their PCTs how that can be put into effect in the local development plans. Some of the objectives in the strategy are more rigorous than those which are within the White Paper commitments. What we have to see now is how that really does come down to PCT level and how that is delivered and monitored within London to make sure that that is happening.

Q43 Dr Taylor: In London, that is at chief executive level?

Ms Weyman: There is a cabinet of chief executives and they decided that they would look at this as one of the issues which they consider across the whole of London together. They chose this as one of their issues. They have been working on it now for I suppose about a year to lead into the local development plans for the coming period.

Q44 Dr Taylor: On the PCT lead, would you have a direct route to get in touch with the chief executive of your strategic health authority? How helpful would the public health specialists be in this field?

Dr Ford-Young: I think it would be very variable from PCT to PCT and PCT lead because we are very disparate people. I am a GP; a PCT leader could be a health promotion officer; someone else might be the director for public health.

Q45 Dr Taylor: Is there some sort of recommendation we should make on that?

Dr Ford-Young: I think the recommendation should be that a sexual health leader in a PCT should be somebody who has some clout within that organisation.

Chairman: May I thank you for a very helpful session. We hope we can take things a bit further. We are grateful for your participation today.

 

Memoranda submitted by Terrence Higgins Trust, African HIV Policy Network and National AIDS Trust

 

Examination of Witnesses

 

Witnesses: Ms Lisa Power, Head of Policy, Terrence Higgins Trust, Dr Max Sesay, Chief Executive Officer, African HIV Policy Network, and Ms Deborah Jack, Chief Executive, National AIDS Trust, examined.

Q46 Chairman: May I welcome our next group of witnesses, Lisa Power, Dr Max Sesay and Ms Deborah Jack, and thank you for your willingness to come before the Committee. Obviously, we are looking in particular at the background to HIV charging for overseas visitors. I wonder if Deborah Jack could give us a brief background to what you believe to be the main issues and problems with regard to the recent introduction of charges for HIV treatment.

Ms Jack: First, we would like to thank the Committee for taking forward our suggestion to look at charging because we do believe it is a really important issue. The first point to make, having talked about the Sexual Health Strategy, is that one of our real concerns about the changes in the charging regime is that potentially they are going to undermine what we are trying to achieve for the strategy in terms of encouraging people to come forward for testing, particularly within the African community. That is a fundamental point, the interrelationship between testing and treatment. If treatment is not readily available, people are going to be reluctant to come forward for testing. They are going to be unaware of their diagnoses. If they do not have access to treatment, they are likely to be more infectious; they are less likely to accept advice on how to avoid onward transmission; and they are also going to be more susceptible to other infections like TB. There are an awful lot of risks there. Another really important point that we picked up is that there has been no evidence of HIV related health tourism which is often quoted. In fact, the evidence we have, and Lisa Power can talk more about this, shows quite the reverse is happening. There have been no financial cost benefit analyses of the impact of introducing charging. The estimates we have done show that the cost of acute treatment in A&E if people who are HIV positive become quite seriously ill is likely to outweigh the ongoing cost of them having treatment. You have to add to that the potential cost of new infections, which the Department of Health is saying is anything between £0.5 million and £1 million a year. Obviously there are fairly significant public health issues but no public health impact assessment had been done before introducing the changes.

Q47 Chairman: You are saying that there has been no evaluation by the Government whatsoever of the implications from the public health perspective?

Ms Jack: No, they have not done the sums and they have not done a public health evaluation either of the implications of it.

Q48 Mr Burns: If one divorces it simply from HIV-AIDS, because that tends to emotionalise the issue, and talk about health care across the board, why should it be that, except for those countries around the world where we may have reciprocal agreements in one shape or form, anyone should receive free NHS treatment, given that British subjects travelling to any country in the world where we do not have any reciprocal agreements would have to pay for their treatment there?

Ms Jack: That is an issue we could debate for an awful long time. I am worried that what we are looking at is specifically HIV in the context of this issue.

Ms Power: The simple answer is that we are responsible for the public health of the UK and not the public health of those other countries. The arguments for exempting HIV alongside the other exemptions which already exist - and I think the Committee is probably aware that all other STIs and tuberculosis are exempted from all treatment charging in the UK for anyone on the ground of public health - are compelling for HIV to join those other conditions and be treated. We have the evidence to show you on that. I think we need to take that on the evidence for the UK because it is our country and these are our budgets.

Dr Sesay: There are broader social arguments for that. I think the charging will be targeting the most vulnerable communities. We are talking about failed asylum seekers, undocumented migrants and of course people who overstay as well. We are looking at the consequences of such a policy on, for example, the spirit of a community based organisation. So we have to bear the brunt of the people who cannot present at their statutory services - that is the whole issue of the exacerbation of a stigma around HIV - and also to a certain extent the heightening tensions around racial harmony within society because the impression or the messages that will be sent will be of foreigners and African communities being not welcome in this country. What is even more serious is the issue of late presentation which is already happening with African communities. I think the evidence suggests that in fact, far from people flying in to access the services in the UK, there are actually problems of late presentation, problems of getting Africans to services, and this is significantly going to undermine all the efforts that have been made at community level to try to get people to present at services. Above all, I think it would have the consequence of driving the infection underground, and therefore the public health we are talking about is actually put at risk.

Q49 Mr Burns: If one takes that logically, do you think that this policy has the effect with regard to race relations within this country that, rightly or wrongly, there is a view that people are having to wait longer for their own health treatment here because of the demands being placed by other people seeking help who have not contributed at all financially to the paying of the service or its practices or whatever?

Ms Power: I think the issue is an important one, and the fact is that we would like to curb the spread of HIV; otherwise we are going to have far greater problems with access to HIV and sexual health services in the long run. We have undertaken research, because nobody else had done it: we have looked at 60 people who were recent migrants who had approached the Terrence Higgins Trust or George House Trust for support - and both of our organisations give basic support to any person with HIV who approaches us, so their immigration status would not matter in approaching us. The research showed that 75 per cent of the people who had recently migrated were not diagnosed until they had been in the UK for at least nine months, which does not suggest treatment tourism in the least. Only five per cent of those people had been diagnosed before entry or immediately upon entry and 58 per cent had only been diagnosed once they were actively unwell. Once someone is actively unwell they are more liable to be able to pass on the virus and they are also harder to treat and more expensive to treat. I think it is extremely important that we are aware that we have people in this country who have a condition which is transmittable and it is more expensive to not treat than to treat. For example, there was a long-stay visitor in North London who was rushed to hospital with pneumonia. This is a case that was brought to our attention at Terrence Higgins Trust. She was diagnosed as HIV-related and therefore billed after four days for £2,000. Because of that billing, she discharged herself, went home and self-medicated, and after several days collapsed and had to be admitted to intensive care, where her further costs came to £23,000 for that episode alone. HIV treatment for one year now in the UK is less than £10,000. The simple fact is that it is cheaper to treat someone for HIV than it is to allow them continuing revolving-door episodes in intensive care for which they will run up bills that they cannot possibly pay and for which the NHS will become responsible.

Q50 Dr Naysmith: As far as HIV treatment is concerned, is there any evidence for health tourism, meaning people who come to this country -----

Ms Power: This is literally the only survey which has been done, which showed that for one in 20 people there may be some case. We are very clear that we are not debating the issue of health tourism in general or government actions around that. We are here to talk about HIV as a public health issue and a public purse issue.

Q51 Dr Naysmith: Certainly that is the way we have always treated it. But this is something that is said and we need to know if there is any evidence you know of.

Ms Power: That is the evidence we know of.

Q52 Dr Naysmith: I accept you do not want to promulgate it, but does anybody ... Deborah? Dr Sesay?

Dr Sesay: No.

Q53 Dr Naysmith: What do you say when people say that to you? - that it happens.

Ms Power: Nobody is debating that it may happen sometimes, but the only evidence which is provided on the other side is anecdotal and occasional. This is a matter which has been supported by the British Association for Sexual Health and HIV and providers of AIDS care and treatment, who are the two key bodies of clinicians and managers in the health service who are working with HIV.

Q54 Mr Bradley: You have already started to experience some of the evidence in your memorandum regarding the effects that have been coming through for the changes. Would you like to elaborate a little bit more on that? Also, have you any evidence that it is adversely affecting those who are eligible for NHS treatment as well as those who are not?

Ms Power: Yes, we do have. One West Midlands' client of the Terrence Higgins Trust was wrongly billed for treatment. Her asylum case had been refused, but she was allowed to remain in the country because her country of origin was too dangerous to return to, and thereupon she was wrongly billed for treatment. She left treatment and fled the hospital. When we attempted to negotiate that with the hospital and to discuss the fact that we believed they were billing her incorrectly, they passed our details on to a debt collector and we were then required to cite confidentiality issues because the debt collector began to try to pursue that person through us. We also talked to a leading North London hospital in HIV who had reported to us that patients were increasingly being lost to follow-up because of the fear of being billed. Our own helpline reported to me yesterday, when I asked about this, that we have seen a serious increase in the number of people who are calling, from maybe a couple of people a week to several people a day, asking about eligibility issues, because they are afraid, because they fear they may not be able to go in, and they do not want the shame of being told that they cannot have treatment unless they pay.

Q55 Mr Bradley: In your memorandum, you have made some reference to that. Could you supply us with up-to-date figures on those sorts of inquiries that you are getting?

Ms Power: I can certainly supply them to you after today. At the moment that is just the communication I have had verbally with them yesterday.

Q56 Dr Taylor: I think you have made the case absolutely, utterly, completely. One of the huge arguments is to persuade people to spend money now to make a saving for the future. I think the work your Terrence Higgins Trust has done - particularly, thinking of your booklet on clinical trials - is absolutely invaluable. I am rather widening it from just overseas people coming here because I think that has been answered. It is absolutely essential that they do not have to pay. I think their surveys are so valuable that it is worth quoting some of the things out of these - and it is really going back to the first session: 15 per cent of PCTs do not have consortia arrangements; almost one-third of PCTs do not include HIV or STIs in their local delivery plans; some still do not have a designated sexual health lead; 40 per cent of PCTs have insufficient capacity to make any progress at all. This is an incredibly useful document with the background in it. Really I find it hard to ask questions that have not been answered already, related particularly to African people living in this country. Could Dr Sesay spell out actual issues that come before some of the Africans living with HIV here?

Dr Sesay: With African communities generally we are talking about communities which are already socially excluded within the United Kingdom context. A lot of them would be asylum seekers; a lot of them would be unemployed - they have a high representation in these numbers of the unemployed; and a lot of them would have been separated from families as well and they come to this country traumatised as a result of experiences from where they come. Some of them do not even know how to access NHS services. It takes quite a while, it takes quite a lot of work at the community level, in terms of providing information, in terms of providing direction, and then imagine, when they try accessing services, what they would encounter is that they will be refused.

Q57 Dr Taylor: If they go to a general practice and if they are registered with one, will they be signposted in the right direction or may they not even be ----

Dr Sesay: I think the charging proposal is going to be extended to primary care, which means that they may even be finding it extremely difficult to get a GP at that level. So when we talk in central government planning around improving our reducing health inequalities within society, this simply cuts across and drives right into the base of central government policy of encouraging people to present to services.

Q58 Dr Taylor: So the impact is disastrous.

Dr Sesay: It is completely disastrous.

Q59 Dr Naysmith: I just want to pick up something that Richard was talking about a little bit earlier, without in any way disagreeing with the fundamental public health principle he was promulgating that it benefits us all if people are not discouraged from seeking treatment. When we were doing the inquiry a couple of years ago, a lot of people told us that one of the things that was happening of course was that funding for HIV/AIDS was being transferred from a special budget to general funding. That must explain at least some of the results that were picked up in your survey that Richard was quoting about some PCTs not spending any money on HIV/AIDS. That should be something that went through a transition, and maybe when these figures were compiled it was still moving. Is that the case or are there some PCTs who do not spend any money in this area at all?

Ms Power: I think it is important to point out those survey figures are from last year, so they are extremely up-to-date. That is a brand new publication. I think there is a real issue ongoing - I am sorry, this is harking back to the earlier session - around the implementation of the White Paper in order to ensure that PCTs take the issue sufficiently carefully. But I think it also spills over ----

Q60 Dr Naysmith: This special budget for HIV/AIDS which was seen as separate from ----

Ms Power: The ring-fenced budget. The money is still there. It is not ring-fenced, but the money should still be there, plus there are a number of special allocations. The question is to encourage primary care trusts to use that money for the purpose for which it was identified and not to move it into other budgets.

Q61 Dr Naysmith: Some are moving it into other budgets, is the implication of what you are saying.

Ms Power: Yes, that is right. And that spills over into the system in that primary care trusts throughout England are actually taking very different attitudes around this, and the cases that I have given to you are cases which we have been able to support, and sometimes we can get people treated in one place and not another because there is absolutely no uniformity of implementation around this and it makes healthcare an extreme lottery. It also means that clinicians are being encouraged to ignore government regulations, which is extremely unfortunate and not a good situation, and it means that there are severe health inequalities emerging for many African people, as Max has been talking about.

Dr Sesay: The African HIV Policy Network is an umbrella organisation that has member organisations, most of them African-led organisations, providing services across the country. We have also established African forums and bringing together regional organisations to work together and to provide services. Since the removal of the ring-fence, what we have realised, what we have seen from our membership and what we have got from the membership of the AHPN, is that a lot of the organisations have collapsed. They have shut down. These have been extremely vital and crucial conduits to very hard to reach communities. They are simply not getting the funding that they need to be able to provide services to the communities at a time when the government strategy should be to enhance the capacity of these affected communities. Those are the contradictions that we are having at the moment.

Q62 Chairman: Simon touched on the politics of this whole area earlier on and Richard's comment was that you have made the case completely, and I would concur with what he has said. Having said that, and in the run-up to a general election where asylum, immigration, race will be undoubtedly, as we can see already, play a key part, how do you address the Daily Mail agenda on this issue and actually get across the important points that you have put to this Committee today?

Ms Jack: I think one general point is we need to divorce this discussion we are having today from general policies on asylum and immigration, because we are talking about people who are living in the UK already with HIV and, irrespective from any other debates around immigration, this is about a real and immediate problem which is not going to go away if those policies change. I think that is a challenge for us, but I think it is really important, because, once it gets sucked into those wider issues, you actually lose the ability to look at it as a very specific problem that can be addressed quite simply by making HIV exempt in the same way as other STIs and TB.

Ms Power: This is not just an HIV issue. A very large part of this for us is co-infection with HIV and TB. We have a number of cases where people have abandoned their TB treatment, because they have been billed for the HIV portion of it, within a couple of weeks of starting it and walked out into the community still infectious to both conditions and with TB quite possibly multi-drug resistant because of partial treatment. That is a very immediate concern. This is about a change of regulations, not primary legislation. I think it would be something that could be put in with the next set of regulation changes which we know are about to happen, and I think it is really important we encourage the Government to put the public health of the nation first on this.

Dr Sesay: We would encourage politicians to be conviction politicians.

Q63 Chairman: That is a pretty old-fashioned concept!

Dr Sesay: I know this can be extremely difficult with an upcoming election, but I think that, if politicians are provided with the evidence, I would encourage them, no matter how difficult it is, no matter .... well, I do not want to say no matter what the political price, because that may well be a high political price to pay, but, when they are presented with the evidence, it is a case of arguing out the evidence and establishing a policy, putting in place a policy that is based on the evidence. One of the things we discussed at the Independent Advisory Group of the Sexual Health Strategy a couple of days ago was exactly that, that we know that sometimes the political terrain can be extremely hazardous for politicians, but if it is based on firm evidence they should be able to get the facts across, and we can only encourage politicians to go down that route.

Chairman: We are most grateful to you. Thank you very much for your evidence.

Memorandum submitted by Health Protection Agency

 

Examination of Witnesses

 

Witnesses: Dr David Asboe, Consultant in Genito-urinary Medicine, Chelsea and Westminster Hospital, Dr Barry Evans, Health Protection Agency, Ms Pam Ward, Co-Chair, Overseas Visitors Action Support Group, and Mr Peter Nieuwets, Chair, English HIV and Sexual Health Commissioning Group, examined.

Q64 Chairman: May I welcome our final group of witnesses this morning and express the Committee's gratitude to you for your participation in this inquiry. Perhaps I could ask you to introduce yourselves briefly, starting with you Dr Asboe - a very interesting name in the current -----

Dr Asboe: It is probably Scandinavian, but I am from New Zealand.

Q65 Chairman: We might be related!

Dr Asboe: I am a consultant in genito-urinary medicine based at Chelsea and Westminster Hospital. I lead the HIV out-patient department there.

Dr Evans: My name is Barry Evans. I am from the Health Protection Agency and one of the HIV epidemiologists within that organisation.

Ms Ward: I am Pam Ward. I am co-Chairman of an overseas action and support group for overseas managers nationally.

Mr Nieuwets: I am Peter Nieuwets. I am an HIV commissioning manager for West Sussex. I am the lead for Kent, Surrey and Sussex and I am the Chair of the national HIV and Sexual Health Commissioners.

Q66 Chairman: Thank you very much. Could I ask Dr Evans, first of all, what is the size of the problem regarding HIV patients who need treatment and care but are not eligible? You were present for the previous session, you have heard the evidence that we picked up there. What are your thoughts on the extent of the problem?

Dr Evans: The data we have within the Health Protection Agency does not give us information on eligibility directly and we have to make assumptions across other data sets. We do know that the number of people who have acquired infection in Africa has been growing very rapidly over recent years. The number of people with heterosexual diagnoses was around a thousand in 1999 and about 4,500 in 2004 - or will be once we get our latest reports in. That increase has been very marked. Also, with heterosexual new diagnoses, about 80 per cent are in African people, people who acquired infection in Africa, about ten per cent in other parts of the world and ten per cent have acquired their infection heterosexually within the UK. One has to then make some assumptions about how many of the African people who have been newly diagnosed within a UK context may or may not have been eligible for treatment. So the numbers are rising very rapidly, the problem is in knowing how many of those people might or might not have been eligible for treatment.

Q67 Chairman: Do you have any observations on the evidence that we have heard in the first session? Would you concur with the picture that was portrayed by the witnesses?

Dr Evans: I would concur with the problems around tuberculosis and the interaction on HIV and TB and of tuberculosis being an increasing public health problem and of not treating HIV-infected people. The majority of people from Africa will have come across tubercle bacilli sometime in their history - I mean, if they grew up in Africa. That does not mean to say they have active TB. But, in the presence of HIV and with the immune suppression of HIV, it is likely, when the immunity drops to such a level, to reactivate the TB and they will then become infectious with tuberculosis as well. If people are treated at the right time, hopefully they will not become infectious with TB, but if you do not treat them, they are going to reactivate their TB - and TB as an initial AIDS-defining illness is rising in the UK, even with current patterns. The other issue is an issue of concern with mother to child transmission. We have not talked about that in the evidence so far. It seems to me, if you are diagnosing women in pregnancy, you have at least the moral right to offer them treatment, and not just treatment in terms of preventing mother to child transmission but ongoing treatment, and yet if you do not diagnose them in pregnancy a significant number of those children will become infected. Round about 800 women in 2003 were infected with HIV and pregnant. The majority of those were diagnosed in that pregnancy; some were diagnosed previously; and some unfortunately did not get diagnosed at all during the pregnancy. The majority were diagnosed and consequently 100/150 children were prevented from becoming HIV infected by the treatments that were offered during pregnancy. Those children would become infected if one did not offer the antenatal screening. The NHS has done well in terms of rolling out. We go back to the days of the mid- to late-1990s, when the vast majority of pregnant women in this country did not have their HIV diagnosed, and that has consequences for the women and for the babies, about 25 per cent of whom, if the women breastfeed, will become infected without treatment for their HIV.

Q68 Chairman: Coming back to your earlier point about TB and HIV, you do not dissent from the concerns expressed about the difficulties for public health if we have the kind of picture that was portrayed by some of these witnesses previously of people with TB and HIV disappearing as a consequence of being billed for the HIV elements of their treatment.

Dr Evans: That is a serious concern. At the moment the overlap of the TB and HIV epidemics is not very great. The majority of our TB patients in this country have acquired TB overseas but are from the Indian sub-continent, where there is less of an overlap with HIV. With African patients, clearly there is some overlap, but less so. Five to seven per cent is our best estimate of the TB patients who are probably HIV infected, so there is not a big overlap, but there is sufficient overlap. And that will get worse if we do not treat HIV, so that TB becomes a bigger issue there. The exact qualification of all that I think is difficult but there is concern that it will get worse. There are concerns about multi-drug resistance if people are partly treated for tuberculosis. There are concerns that, even if one treated the TB, then people need their own immunity to completely eliminate the tubercle bacilli. If you do not treat them for HIV, they may at a later stage again react the tuberculosis.

Q69 Dr Naysmith: I was going to ask Dr Evans about the public health consequences of what happens if charging puts patients off under four separate headings. We have already dealt with two of them, mother to child transmission and the spread of TB, and presumably the same would apply to other sexually transmitted infections. I would just like to ask you what would be the effect, if this is a discouragement on people seeking treatment, on the spread of HIV within the wider population in this country - which you have partly touched on already - and also the impact of this policy on HIV testing initiatives.

Dr Evans: I think in both those areas it is again difficult to quantify, but on the issue of the onward spread of HIV we have reasonable data now that shows that the spread of HIV is strongly related to viral load. Viral load rises with the progression of the infection. As the CD4 count, the level of immunity drops, the viral load rises, and with high viral load is much more likely to transmit. If people are not diagnosed and they continue to be sexually active, they are more likely to transmit the higher the viral load. There are other co-factors affecting transmission, including other sexually transmitted infections and so on, but viral load is a powerful indicator of transmission potential, so that if you do not treat individuals and they remain in this country and are sexually active in this country, then the transmission is bound to go up. The quantification of that and the total amount of transmission within the UK is going to be quite difficult and would need some fairly complex modelling.

Q70 Dr Naysmith: You said it is bound to go up. It will go up, of course, but it will be reduced a little bit if people use protective measures. What is the evidence that people coming to clinics will be advised about this as well as receiving treatment and will then not be advised about possible ways of limiting the spread of their own disease?

Dr Evans: I agree with that: they can be advised. I think the advice, though, needs to be seen within a total care package and if you cannot offer treatment within a total care package then I think it becomes much more difficult.

Q71 Dr Taylor: Is there any argument in favour of charging for HIV treatment and not charging for the other communicable diseases? Is there any argument against? Is it purely and simply financial?

Dr Evans: I think the only argument that I can find is that of public purse. We would not be here having this debate if with HIV treatment one could treat it for a fortnight and cure it, if it was like syphilis or other sexually transmitted infections which with a course of antibiotics or antiviral treatment you cure the patient. It is a public purse argument largely, and the complexity of HIV treatment and the need, as you are well aware, to keep people on treatment long term. We do not have a cure; we just have a means of suppressing viral load.

Q72 Dr Taylor: Do any of the witnesses have any idea how we get this across, that in fact it is not a money-saving exercise because of all the long-term consequences? How do we get this across?

Dr Evans: The only thing I can think of, in terms of having thought and grappled with this - and we have had no evidence that this occurs - is, if people know they can get treatment, this issue of potentially could we be seen as a magnet to attracting more people in terms of treatment tourism in the future. There is no evidence that it is happening now - very, very small anecdotal reports, but nothing now - but if in the future the HIV epidemic worldwide continues, are we encouraging people if we are seen as offering treatment to everyone? That seems to me the only reason. There are powerful public health arguments against that. If people are living here, there are powerful public health arguments to treat them appropriately.

Q73 Dr Taylor: Have you hit on the real hidden reason? Because obviously one could see a government being absolutely terrified of attracting huge numbers of people to this country just because they get treatment free.

Dr Evans: Then the issue of appropriate migration ... Even people treated in this country, who come to this country and are treated, in general those are people who are going to get into work on treatment and who will contribute to the British economy. They are people who cost money in terms of their treatment, but the total public purse argument needs to be taken into account.

Q74 Dr Taylor: In a way you cannot separate it, as you tried to, from the whole immigration issue.

Dr Evans: I am not a politician.

Q75 Chairman: Neither is Richard!

Dr Evans: I am thankful I am this side of the table and not that one.

Q76 Mr Burns: As you are aware, there are a number of categories of groups of people who are now ineligible for free secondary care in this country and, possibly, depending on where the Government's consultations go, that might be extended to primary care. What advice did your agency give the Government in the consultation process on primary care and on the Government action on secondary care?

Dr Evans: I am not sure what advice we gave and whether we submitted written advice. I am sorry, I should know that

Q77 Mr Burns: Presumably, as the Health Protection Agency you did input to the Department of Health as part of the consultation process.

Dr Evans: Yes, we did, and there was concern about the rising number of sexually transmitted infections and increasing diagnoses of HIV - and that was in the submission, I know - but I do not know the detail and I am fairly sure we did not raise the issue of migration.

Q78 Mr Burns: As part of your work, do you monitor what goes on elsewhere in the world to see if you can learn anything?

Dr Evans: We submit the UK data to a European centre, and we look at what is happening in terms of other countries via UN AIDS data that comes out on a regular basis, yes.

Q79 Mr Burns: Are there any other countries in the developed world that you know of that will allow people to come from outside their borders then to get free treatment for things like HIV/AIDS?

Dr Evans: There are some countries. There are countries who have screening at point of entry. There are some countries that it is difficult to know: they do not separate HIV from other long-term chronic illnesses. But, for instance, if people are seeking to emigrate to Canada, they would treat HIV as the same as they would renal failure -----

Q80 Mr Burns: I do not want to get into screening because other colleagues of mine, I know, will be raising that. I do not want to get into emigration either because that is a slightly different issue as well. I am asking if you have evidence of any other developed country in the world where, if one turned up inside their borders, on holiday or whatever, and then presented oneself at a hospital and it was diagnosed that you had HIV or a number of other conditions, one would be able to get free treatment.

Dr Evans: I am not aware of that, but I would not be expected to know, quite honestly. I do not know what other countries' policies are on that.

Q81 Mr Bradley: Peter, we have heard some evidence on costings. What is the up-to-date cost of HIV treatment? How does that compare with someone falling ill and using emergency services? How does that compare with an attempt to prevent someone having further infections?

Mr Nieuwets: There are a few answers and a few things I cannot answer. First of all, combination therapy costs approximately £7,000. But that is just the combination therapy, that is not the sum on-cost, because most of the time on-cost for a patient is £12,000 altogether. That is what a patient approximately costs. If you can prevent that - and prevention, it is said, could cost up to a few pounds - if you look at what a PCT spends on prevention on HIV and what it spends on the actual cost of treatment, those two have no relationship to one another. One PCT could spend up to £3 million on treatment, and very little on prevention because HIV does not have a star rating. Teenage pregnancy has. They will try to prevent teenage pregnancy, but not HIV because it is not seen as important. On the other side, in some PCTs they still say - and sometimes I am surprised - "We don't have any gay men, we don't have any black people" and then you have to say to a director of public health, but the SOFIT data proves you have.

Q82 Mr Bradley: With the emergency services -----

Mr Nieuwets: I do not know exact costs on that, but if people come in through A&E they are much more expensive because it is also the time and everything being spent on them and they become an in-patient. It is very clear if people also have HIV and, for instance, they are dying of HIV. It was estimated a few years ago from Dr Beck that it costs up to £50,000 to £60,000 a year for somebody dying of HIV, not everything else, because somebody just does not die, it takes a long time. That is one of the problems that also some of my other colleagues put forward. It is, like, if you cannot treat, people will get ill and will need lots of A&E treatment, which is expensive, and then leave and will turn up after months again. One of the problems is often that people will shop around because they will be fearful to go to the same hospital because hospitals, lots of them, have administrators with good memories. If a name comes up, they say, "This patient hasn't paid their bill last time." Then you get into the issue of: Is it treatment or is it payment? What is the most important: to treat or to pay? Some people are very wary about that. They say, "But if I don't pay, they don't treat." It is also an enormous amount of tension within hospitals between administration and medical staff: Treatment or payment? Who has the loudest voice within the hospital? And it creates an enormous amount of problems for a community. According to the strategies, we are working against social exclusion, we are targeting vulnerable groups. The effect of this, in a way, is that we are targeting vulnerable groups but socially excluding them, not including them, and financially this has enormous problems. If you look at the numbers, numbers of HIV go up by 20/25 per cent across the country. The costs, what PCTs get, go up by ten per cent, so the pressure on the services is growing, and a PCT says, "We don't have money," "Yes, they have money," says the Government. "It is in the baseline." But the baseline is based on SOFIT data of 2001 and has not changed. So there is a problem there.

Q83 Chairman: Mr Nieuwets, you mentioned tensions between doctors and managers in this whole area. Dr Asboe, without being specific about Chelsea and Westminster, would you concur with that picture? Is it one that you pick up from your colleagues elsewhere?

Dr Asboe: I think in many areas there is a conflict. First of all, the criteria on which patients' eligibility is assessed are complex and difficult. In many situations, you are asking clinicians at the coalface, you know, at the point of entry, when patients are being tested, to make that assessment, an assessment that is difficult. Patients are often very traumatised in that setting and clinicians are not trained to make that assessment. It also puts them in conflict with their primary role. Making the basic assessment at that level can be very difficult. There is also a situation where patients may not be eligible for treatment, and it is not only that they are not eligible but the guidance is that if treatment is deemed to be necessary in order to save life or to prevent a life-threatening illness, then treatment must be offered immediately. But you may have one commissioner in one hospital who takes a criterion of a CD4 count of under 200 - so a patient is very immune compromised, but not at this very point in time having a life-threatening illness - who will make the decision that treatment is warranted under those circumstances and you may have a clinician in a different hospital or on a different day who makes a different assessment. Then there is not only conflict between clinicians because the criteria are not very clear but you have conflict between the clinicians and the management, either of the trust or, at a higher level, the PCT level. So I think this conflict often is difficult and will be more severe in different trusts.

Q84 Chairman: If a patient is being treated for a range of conditions and certain of those conditions are free and certain chargeable, what impact does that have on you as a doctor treating these people? Who actually works out how much is free and how much is chargeable?

Dr Asboe: That is very true. I work in the sexual health service as well and so obviously patients coming into that service, the sexual health or the STI component of it, excluding HIV, is completely covered. Okay. But as part of that service we are offering testing to everyone, and a proportion of those patients will test HIV positive. Then you have to turn round and say, "Well, we can treat your syphilis but we cannot treat your HIV." I think it comes back to the whole point: in a way -----

Q85 Chairman: Could I just intervene. You can treat it but it would be chargeable.

Dr Asboe: It would be charged for.

Q86 Chairman: How do you work out the proportion which is chargeable where surely there is an overlap between the treatment of the conditions?

Dr Asboe: The treatment of HIV is very specific. You have combination antiretroviral therapy which is specifically for that condition. The only overlap with those drugs is the treatment of hepatitis B, and sometimes that is an issue. Some patients may be able to have their hepatitis B treated but not their HIV. In terms of their other sexually transmitted infections, actually the treatments are quite disparate and separate but obviously they can occur in the same person.

Q87 Dr Naysmith: You are acting as a kind of gatekeeper in this situation, are you not? You are deciding who has to pay and who has not. Is that a role that you are happy with?

Dr Asboe: Absolutely not. It is very clear that the General Medical Council says in the duties of the doctor, the very first one, that you must make the primary care of the patient your first concern. You must work with your colleagues to ensure that the patient's best interests are served and that is in direct conflict with some of these decisions that are needing to be made. You may say you can refer them to the overseas officer, but, in fact, where is the clarity about who gets referred, how they are assessed and how often they are assessed? So there is major conflict.

Q88 Dr Naysmith: You must know that sometimes you are denying treatment to patients who do not have the money to pay.

Dr Asboe: In practice, if we had a patient attending our service about whom we felt, from our assessment and in conjunction with the overseas officers within the hospital, there were questions about their eligibility, we would refer them onwards to see specialist legal advice, usually from the Terrence Higgins Trust.

Q89 Dr Naysmith: Does that cause you any other problems apart from the sort of ethical one?

Dr Asboe: I think it is a problem for the patients. It may have been difficult for them to attend the service, they need to go outside the service to get this legal advice, and then often they are lost to follow-up because they never actually make it back into the service, they become part of the hidden population who are a threat with all the problems that HIV can lead to.

Q90 Chairman: In reality, again without asking you to comment about your own position, would it be fair to expect perhaps rather a lot of medical colleagues in your circumstances to turn a blind eye to requirements on charging and carry on treating? Is that not a reasonable assumption to make?

Dr Asboe: I am sure that happens. That is because, in talking to my colleagues, we feel that is our duty as a care giver. We know that may put us in trouble with the trust, but, equally, the converse of that is that if you withhold treatment you may be in conflict with your duty as a care giver.

Q91 Dr Taylor: The impression is that it is unenforceable. You have said one is allowed to use treatment where it is necessary to save life. Is there a sort of time limit on that?

Dr Asboe: I should say that it is your duty to use that treatment now to save life. It does not mean the patients will not then be charged for that treatment. It is not that it is free, but the circumstances in which you would invoke that and just get on and treat the patient - and then obviously trusts will have a variety of different views about whether they will chase the person for the money, how hard they will be chased, and where the patient stands on this, in terms of having been diagnosed with a life-threatening illness and being chased by debt collectors and the like. But I do not mean to give the impression that treatment under those circumstances is free.

Q92 Dr Taylor: Thank you for clearing that up. You have mentioned also that you refer things to the Terrence Higgins Trust for legal advice. Do you delay treatment while you get the advice, or do you treat and then go for the advice?

Dr Asboe: Again, I think you would make a clinical assessment and if you felt treatment was immediately necessary, either for the person or, quite often, as we have heard -----

Q93 Dr Taylor: Public health.

Dr Asboe: Or in order to prevent vertical transmission - so if a pregnant woman came in we would get on and do that and then ask the questions later, of course.

Q94 Dr Taylor: What would you ask for legal advice about? Would it be simply: "Can I treat this patient?"

Dr Asboe: We may have got a decision from the hospital side of things that this patient is or is not eligible for treatment, but I think it is very important that a different organisation, perhaps who will act in an advocacy role, also will -----

Q95 Dr Taylor: When would you get that decision from the hospital, from the trust?

Dr Asboe: If a patient comes in for HIV testing, let's say in a sexual health clinic, if it is thought that eligibility may be a problem, that would be discussed with the individual presenting for testing before they go ahead and have the test. They then proceed with the test and the result comes back positive. Then again it will be discussed. We will discuss it with the hospital overseas officer to get their view, and then, if it is a problem and there is no urgent medical problem, we would refer the patient to the Terrence Higgins Trust, first to clarify whether that was Terrence Higgins' view or whether there was a discrepancy there, and then obviously they would advise the individual about what their different options were.

Q96 Dr Taylor: Could you clarify the position when there is no urgency.

Dr Asboe: That is a clinical decision.

Q97 Dr Taylor: Does that go on the protection of other people from the spread?

Dr Asboe: No. Generally that would be an individual clinical decision about that person as an individual.

Q98 Dr Taylor: So it is an absolute minefield for you to work through.

Dr Asboe: It is a minefield.

Q99 Dr Taylor: Could I go back a little bit to Peter. We are told that government targets are aimed at reducing newly acquired HIV infections; they are aimed at reducing undiagnosed HIV infections. What effect will these changes have on those targets?

Mr Nieuwets: They become very difficult. Several people said when those targets came out, "We might achieve them if you build a very big wall around England - a very big one which no one can get through, neither getting in nor out." Then it might be achievable. But if it is an open country, it is unachievable - even probably within the country it would have been very difficult. Especially one of the factors now is that people go underground: you do not even know any more how big your undiagnosed group is. One of the other problems with the effect of these regulations is that with lots of partnership arrangements within community care, between people from the black African community and organisations, HIV organisations and other organisations, the trust within those very fragile structures is also falling away, so people do not trust each other any more. They do not trust medics, they do not trust PCTs, and everybody asks: "Who is doing what?" The chance of offering good community care is even going down the drain with this, so it becomes very difficult even to keep that on a level, especially then, over time, if money gets less and less. Because all the money is pumped into combination therapy and PCTs understand lots of times that money has to be paid to treatment. Community care is really the stepchild of this. It is like nobody is really bothered about this: "That is not really necessary." If you ask clinicians what is the most important thing about treatment, it is adherence. Good adherence is lots of times helped by good community care. If there is no community care, the adherence will drop and you will have even bigger problems, and financially it becomes a bigger problem. One of the issues is also that the way HIV is funded within PCTs across the country is very different. In some areas it sits very clearly within specialist services and it is more or less still ring-fenced. In other areas, it is in the PCT and has to compete with anything else that is in the PCT while it still officially sits in the specialist services' list. But decisions are made within PCTs and they are given power so they can do that.

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 all money.

Chairman: We tried to build a big wall a few years ago to keep the Scots out, but they appear to have got through!

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 examples?

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 original resident.

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 baby - which does happen - then 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 to manage.

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 was saying?

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 residency - and 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 in general.

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 confidentiality?

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 there generally.

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 government?

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 financially - and 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 per cent 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 levels - we are probably going to end up with 78,000 new diagnoses last year - but we are no longer in the 20 per cent rise a year. That may have political consequences of we are no longer on the steep trajectory of an increasing issue.

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.