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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 252-ii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
NEW DEVELOPMENTS IN HIV/AIDS AND SEXUAL HEALTH POLICY
Thursday 10 February 2005
MS JULIE BRAMMAN MISS MELANIE JOHNSON MP, MS ELIZABETH RYAN and MR GEOFF DESSENT Evidence heard in Public Questions 122 - 258
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 10 February 2005 Members present Mr David Hinchliffe, in the Chair John Austin Mr Keith Bradley Dr Doug Naysmith Dr Richard Taylor ________________ Witness: Ms Julie Bramman, Head of Curriculum, Specialism and Collaboration, Department for Education and Skills, examined. Q122 Chairman: Good morning, everybody. Can I explain that this morning's session is partly reviewing our Sexual Health Report and the progress made since we produced that report 18 months ago and looking at certain issues around HIV and AIDS. For the first part of the morning we have got a witness, Julie Bramman, from the Department for Education and Skills. We are very pleased that you have been able to come before us. Would you briefly introduce yourself to the Committee, Ms Bramman. Ms Bramman: I am Julie Bramman. I am Head of Curriculum, Specialism and Collaboration at the DfES. Q123 Chairman: I think you are aware that when we undertook our inquiry, we did take evidence from your Department and one of the areas of concern to us in sexual health was a feeling that part of the problem that we have in what we described as a 'crisis' at the time and what our witnesses in the last couple of sessions have said has got worse was partly down to the lack of preparedness among children and young people, and I think there was a feeling that our sex education is too little and it is too late. We certainly got evidence that where there was good-quality education, it appeared to delay the onset of sexual activity, so, despite what people think, that if they are explicit and talk to children at a younger age, they will "do it", the evidence actually was completely the opposite. As you are aware, we made some recommendations about including sex education in the core curriculum. Obviously I am aware that since we made those recommendations the Ofsted report has come out a little while ago which was quite critical. What do you feel can be done arising from the Ofsted report and arising from our thoughts about this issue, bearing in mind that we certainly see that what is happening appears to be even worse now in terms of STIs and STDs, the overall problems of sexual health, than it was when we looked at the situation 18 months ago? Ms Bramman: I think the key points that come out of the Ofsted report are around teacher confidence and teacher competence in actually teaching sex and relationship education within PSHE. Where they were looking at specialist teachers, they found really good practice there both across the primary and the secondary sectors, and I think that our priorities have been to increase the level of competence we have and the number of specialist teachers we have who have PSHE as a specialism. Within that, we are running a continuing professional development accreditation process and we have 2,000 teachers on that this year and we have places for a further 2,000 next year. We think that that is really what we need to be doing, making it part of a specialist process, which it has not traditionally been, with geography and history, as it is quite clearly a specialist subject, rather than leaving it to form tutors which seems to be the majority of practice at the moment. Q124 Chairman: Are you weathered to the concept that it has to be teachers because one of the things that we generally wrestled with was whether there might be more appropriate people from outside to come into schools? I have talked to health professionals in my own area where use is made of them by the schools and I think some of them feel that they may be better able to do the job, which is not in many areas being done, than teaching staff. The picture we got from many of our young witnesses was that the staff were ill-prepared and embarrassed, and the pupils picked that up, and that often the feeling was that perhaps somebody from outside would be more appropriate. I have seen in the past in young offender institutions health visitors and midwives go in and talk to some of the lads in, I think, a very helpful way from an outside perspective, not somebody based within that institution, and I felt that that offered a model which we might be looking at. Ms Bramman: Most certainly. We are also running an accreditation programme for community nurses now and have in the first year over 300 community nurses on the scheme to enable them to teach in schools or present in front of a class, as they are not to use the word "teach", as well as encouraging co-location of health services into schools for our Extended Schools programme, including the full service of extended schools, of which there are over 100 at the moment. We have set out in our strategy in one of the five aims that the Department has for young children and young adults, that of being healthy. I think we are forging much closer links with the Department of Health to achieve that objective and clearly it is very much in our minds as a way forward. The general workforce reforms that we are looking at, as a Department, encourage lots of para-professionals into schools so that it is not so much the domain of teachers. Q125 Chairman: In terms of the relationship between education and health, can you just briefly describe whether the steps that are being taken which you have just mentioned are primarily being driven at national and ministerial level or is it that you are encouraging these relationships at a local level with schools and PCTs or is it both? Ms Bramman: I think it is both and I think, particularly through the Healthy Schools initiative that we have where it is regionally based and we have set out some very clear strands and objectives that we have within the Healthy Schools agenda, that is encouraging local networking. It is one of the things that the Ofsted report picked up on, that very good connections were being made locally between the health services and schools and that was a good thing on both sides. Q126 Chairman: So at a ministerial level, and obviously, as you appreciate, we have got the Minister coming here, who do you relate to in the Department of Health? Where is the connection? It is a big department, so who are the people who are driving it forward from your point of view? Ms Bramman: It is very wide-ranging. The two departments now have a protocol on how they will work together and what their joint priorities are. With regard to the curriculum in schools, we are setting up a joint Healthy Schools team which will sit within the Department of Health building, but will have DfES officials as part of it as well, so it really is very much joint working and we work closely with our Young People health colleagues on a wide range of issues, not just sexual health obviously, but drugs and many other aspects that come within the PSHE and other parts of the curriculum. Q127 Chairman: So there is a good working relationship between the departments in moving this forward? Ms Bramman: Yes, there is. Q128 Chairman: In terms of structures that you work to, the Public Health White Paper proposed certain changes at Cabinet level. I am not going to ask you to comment on those, but can you anticipate all the changes that might take place structurally that would be helpful to that working relationship moving forward, as we are talking about this morning? Ms Bramman: Structurally, in the Department we are looking at how we can better co-ordinate across our own structure on health issues because clearly it covers from early years, from SureStart right through to Lifelong Learning and we are very aware that at the moment we have, for want of a better word, lots of silos that could be far better co-ordinated in our interface with the Department of Health, but officials have met recently to discuss how we might restructure ourselves so that we can interface better and reporting through to individual directors general. Q129 Dr Taylor: You mentioned that you are getting some accredited community nurses and you are getting accredited teachers. Is there any evidence, any pointer, as to which are more effective? Ms Bramman: Not to my knowledge. Q130 Dr Taylor: Any comments from students who have had both types of teaching? Ms Bramman: The only feedback I would know about is around the confidentiality with community nurses. It is clearly easier in some respects for young people to talk to someone they are not in contact with within the school full-time and, therefore, I think it is a different relationship. Q131 Dr Taylor: With the 2,000 teachers in training for accreditation, are these from a wide range of other subjects or are they people who are going to be absolute specialists in teaching PSHE? Ms Bramman: It is both. Some are taking it as their main specialism, so they will be PSHE teachers and will teach across the school age. Others are taking it as a second specialism. Q132 Dr Taylor: Would the pure specialists go round different schools or would they just be attached to one school? Ms Bramman: They will be attached to one school, but we encourage very much collaboration between schools through many of our other programmes, such as the Specialist Schools and Leadership Incentive Grant and Excellence In Cities, very much on the theme of collaboration. Q133 Dr Taylor: So if you had got a specialist, you would make the most of that person? Ms Bramman: We would expect the most to be made of that person, yes. Q134 Dr Taylor: The paper we had from Ofsted dated January 2005 actually said that some schools do not provide PSHE in any form and it goes on to say that the position of these schools is untenable. What are you doing about that? Ms Bramman: That would be picked up in the individual school's report. This was a subject report of course, but when Ofsted visits for a whole school inspection, it will be picked up there and become part of the conversation that we had under the new relationship with schools and we will clearly have to have very serious conversations with the school about ensuring it has adequate PSHE just as in the same way as if it did not have adequate mathematics or English. Q135 Dr Taylor: So that would be enforced pretty quickly? Ms Bramman: It would be enforced pretty quickly. The report was helpfully not specific. Q136 Chairman: I think you have also accepted in what you have said before that having a form tutor doing the PSHE role as well as everything else he or she has got to do is not acceptable. Ms Bramman: What I said is that it is probably not best practice. I had not said that it is not acceptable. Q137 Dr Taylor: And you will aim to replace that by these accredited teachers, so how far will 2,000 accredited teachers go across the country? Ms Bramman: There are around 3,000 secondary schools, and many more primaries of course. Dr Taylor: Moving on, we talked to a number of young people during our inquiry and there was the definite feeling that it is okay to talk about sex and sexual health, but you have got to have the round, full picture and you have got to go into relationships because one without the other is certainly lacking something. Is there any evidence to say that this is actually being covered by PSHE or SRE - I get muddled up with the initials - that it is the relationship that leads to the sexual activity which is so incredibly important, so is that being taken up? Q138 Chairman: Can I just say that we actually suggested that SRE should become RSE for reasons that you might understand. Maybe it is indicative of the age of the Committee, I do not know, and probably we are a bit old-fashioned, but we put that forward as a serious suggestion. Ms Bramman: Well, it is sex and relationship education and we do underline the relationship aspects within all of the guidance that we produce. That is why it is so important to teach it within PSHE rather than as something that is separate or just the science aspects of sex. Q139 Dr Taylor: The fact that young people raised it with us made us wonder how effective that amalgamation was, but obviously you are aware of it. Ms Bramman: We are aware of it and it is something, as I said, that we cover in all resources and the guidance that we produce. Q140 John Austin: There is a lot of difference in the figures as to what age sex education begins, but certainly I think there is general agreement that relationships education starts at the very earliest stage. It is relationships education which is the most important and when children get to a certain age, then the sexual side of that comes in, does it not? Ms Bramman: I think that is very right and the evidence that we had back from the QCA monitoring reports on the subject tells us quite clearly that primary schools rank PHSE as their fifth most important subject behind English, maths, science and ICT, so I think that that gives some indication of how important primary schools generally understand about developing the whole child and, within that, including understanding relationships. We are currently, through QCA, consulting on Key Stage 1 and Key Stage 2 end-of-stage assessments in PSHE so that we can guide teachers about what a child of that age typically should understand and know about relationships as well as the other aspects of the subject. Q141 Mr Bradley: Is it, therefore, the intention to make such teaching a compulsory part of the curriculum? Ms Bramman: We are not intending to make PSHE statutory. We do not think that that is necessary or possibly even desirable in terms of continuing to allow schools flexibility on how to deliver PSHE and, within that, SRE in consultation with parents and the communities that they serve, but there is a clear expectation that PSHE should be delivered, so I do not think there is an intention to change the statutory basis of it, but clearly we expect it to be delivered. Q142 Mr Bradley: Yes, but expectation and having it as part of the curriculum, there could be huge gaps, therefore, in the provision, could there not? Ms Bramman: That is what Ofsted inspections will tell us. What we are coming up with is a non-statutory framework for PSHE covering guidance and best practice, as I have said, around the Key Stage end-of-stage assessments throughout all of the Key Stages to give further guidance on how teachers should be delivering and monitoring and assessing the progress of their pupils. Q143 Dr Taylor: Ofsted have said that it is untenable not to have PSHE and you tended to agree with me when I brought that up, but then you said that you are not going to make it obligatory. It has got to be obligatory, has it not? Ms Bramman: At the moment PSHE is not part of the statutory national curriculum, and sex and relationship education is statutory, but what is not statutory is the content. Q144 Dr Taylor: So SRE is? Ms Bramman: Yes, it is statutory. It has a statutory basis with ---- Q145 Dr Taylor: So is SRE not the most important bit of PSHE? Ms Bramman: I think that might depend on which committee you are sitting in front of! Q146 Dr Taylor: Should they not both cover the same thing? Ms Bramman: PSHE is wider than sex and relationship education. It will also cover things like drugs education, for instance, and wider health issues and wider social issues that relate to an individual. Dr Taylor: It seems to be absolutely obvious that SRE and drugs education ought to be obligatory, the whole lot, ought it not? That is certainly my view. Q147 Chairman: Your title as head of various things included collaboration. Ms Bramman: That is right. Q148 Chairman: I am not sure whether Richard touched on this because I was talking to a colleague when he asked his first question, but one of the things that really impressed us in the sexual health inquiry was the TicTac project which no doubt you are familiar with in Paignton and there are other similar models in different parts of the country. Ms Bramman: Yes. Q149 Chairman: I wonder whether you felt able to encourage that sort of approach through your responsibilities at a local level because it struck me that in my own area that would really be so beneficial. I think all of us who went there really felt it was a model that ought to be looked at and it was doing a really first-class job, not just in terms of sexual health, but wider support and advice to youngsters going through adolescence. Ms Bramman: We are encouraging that kind of project to be co-located with schools where schools wish to do it. Clearly it is a matter for individual schools rather than the Department whether or not to go down that track, but it is something that we encourage. We have, through the Teenage Pregnancy Unit, produced guidance and materials about this which include case studies, like the TicTac project and the benefits of it, and our understanding is that that kind of co-location is continuing to blossom really. Q150 Chairman: Can you see that as a logical kind of extension of the collaboration that you described at a local level? Ms Bramman: Absolutely and a logical extension of the Extended Schools policy where we are looking for schools to become the heart of their local community and co-locating health and social services as well as other activities for the pupils and parents to do. Chairman: Can I thank you, Ms Bramman, for this brief session; we are most grateful to you. You are very welcome to stay for the rest of the session if you want. Thank you very much. Memorandum submitted by the Department of Health Examination of Witnesses
Witnesses: Miss Melanie Johnson, a Member of the House, Parliamentary Under-Secretary of State for Public Health, Ms Elizabeth Ryan, Section Head, Injury Costs Recovery and Charging for Overseas Visitors, and Mr Geoff Dessent, Deputy Division Head, Sexual Health and Substance Misuse, Department of Health, examined. Q151 Chairman: Good morning. Can I welcome our next group of witnesses. Minister, I particularly welcome you. We are most grateful for your attendance today. As you are aware, this session in a sense is partly a follow-up to our sexual health inquiry and also looking at the HIV/AIDS issue and the charging regime. Can I ask each of you briefly to introduce yourselves to the Committee please. Miss Johnson: I am Melanie Johnson and I am the Minister for Public Health. Ms Ryan: I am Elizabeth Ryan and I lead on charging for overseas visitors within the Department. Mr Dessent: I am Geoff Dessent, the Deputy Head of Sexual Health and Substance Misuse in the Department of Health. Q152 Chairman: We are very grateful for your co-operation in the inquiry. Can I say, first of all, that I think it is important to place on record that we appreciate the steps that were taken by the Department in response to our Sexual Health Report. We picked up a number of areas where the Government have acted and we generally appreciate the fact that what we suggested has been listened to. Having said that, one of the areas that we talked about, as you are aware, Minister, was the 48-hour access and that was an area where the Government has indicated that steps have been taken to try and ensure that people do have that access at a reasonably quick period from when they know they have got a problem. The evidence that we have got is that that is not actually working. The evidence that we have got from the witnesses that we have had in this short inquiry is that the picture that we got 18 months ago is now considerably worse. I think you will have seen the evidence that the demands upon the service are such that in a sense this 48-hour access is meaningless. How do you see it working and do you feel that there is a need to take further steps to address the problems that are being picked up? Miss Johnson: Did you say at the end of that that you thought the 48-hour target was meaningless? I am just checking that I heard you. Q153 Chairman: I do not think it is meaningless. I think the picture that we are getting is that it is not working because the GUM centres are basically so overwhelmed that they cannot meet that target. Let me just give you an example. Last week I had a meeting with a sexual health project in west Yorkshire, called Yorkshire Mesmac and they particularly help gay and bisexual men. They were talking in particular about the 48-hour target and they were saying that it is meaningless. They said, "For example, at least one clinic in west Yorkshire 'guarantees' an appointment within 48 hours. However, this is achieved by not answering the telephone once all the following two days' appointments are full", and this is from Tom Doyle the Director of Mesmac. They are genuinely worried that people continue to be turned away when they are attempting to access services, knowing that they have got a particular problem. Miss Johnson: Well, you have highlighted one apparent problem there which I am not aware of and I will certainly look into that. What I say overall is that obviously the 48-hour target is very far from meaningless. One of the ways in which we have driven improvement across the Health Service much more widely is by the judicious use of targets in key areas where we need to drive up performance, and all the evidence is that actually that has brought about a remarkable improvement, along with the investment and the reform, in the standards of service, the access times and so forth, so improving the quality of services to patients. I am sure that that will apply with the 48-hour target. The 48-hour target is for 2008 and we realise, because we started from a low base and there is a problem which we have acknowledged and your report has highlighted of sexual health, that investment is only recently going in to sexual health, so that is a target for 2008 which we are working towards. We have got for the first time, as a result of the survey which we have undertaken on that, a good understanding of what the current waits have been. We will get updated information based on the recent survey on that. I believe that that shows a small improvement is likely to be taking place in fact in the waiting times, but we will have to see how that looks and what direction that is going in, but overall £130 million extra has just gone out only yesterday to primary care trusts as part of their funding through the announcement the Secretary of State made in the House yesterday and that money is specifically designed to do things like improve access and GUM facilities and is going to PCTs for that purpose. Now, I know, before you raised the question with me, that there is always a question raised about whether this money goes on and is used for the purpose for which it is meant, but for the first time ever we are actually making sure that the local delivery plans, the LDPs, for the PCTs have to include a reference to what they are doing on sexual health and they will be assessed against that and it will have to reflect the local needs and local demands. I am sure for one thing that your example earlier on is something that is going to be of interest to the commissioners of services in the area of the clinic that you mentioned. Q154 Chairman: One of the problems I was going to ask you in terms of the delivery plan is that I think we gained a feeling when we looked at sexual health that the SHAs, in the healthcare commissioning, needed to play a much stronger role in ensuring that these plans mean something and that the resourcing that has been made available, and we will probably talk about, in particular the resourcing of primary care, actually goes to where it is supposed to go. Can I come back to your point that you seemed to be surprised at the evidence that we have received. You were referring to your MedFASH review presumably, were you, the information in that review, which we have corresponded to you about? Miss Johnson: Well, there was no data on waiting times at GUMs, as I know you are aware, and for the first time last year we actually commissioned a survey of those waiting times, I think in May of last year. Q155 Chairman: Is this separate from the MedFASH review? Miss Johnson: Yes. The MedFASH review is also being conducted, an overall audit separately, which is another source of information about performance and provision which we will obviously be using to inform for the future, but that is not yet completed and we do not have that information. Q156 Chairman: But have you seen the evidence that we got from the Health Protection Agency and the British Association for Sexual Health and HIV which shows that only one-third of patients are being seen by the GUM within 48 hours of trying to access that? Are you aware of that information? Miss Johnson: The HPA published the information, but it was actually information which the Department had commissioned. Q157 Chairman: So you are aware of that? Miss Johnson: Yes, certainly and that is the baseline that we have got. We know that there is a lot of improvement to be made on that. We fully acknowledge it and that is why we have made record levels of investment. Altogether, £300 million has been identified for the purposes of campaigning or improving sexual health, so actually in terms of information and provision, we are accepting that a lot needs to be done and that is what we have done through the White Paper, the investment to follow that and the investment that went out to PCTs to start making the improvements on the back of that. Chairman: One of the things that you are doing in sexual health is an education campaign and obviously we all want to see that. I have a vivid memory of going to Manchester to the GUM clinic there in the Royal Infirmary and being shocked by some of the issues that they raised with us, so shocked that we left Dr Taylor behind in the ladies section of the GUM clinic and we found out when we got to Bolton that he was not on the bus! It was a terrible situation! Q158 Dr Taylor: It is a myth! I was on the bus! Miss Johnson: I think these things should be fully written up! Q159 Chairman: Anyway, one of the issues that I remember from Manchester was that we had the public health people and the GUM specialists together in the GUM clinic and we were talking about the issue of education and screening in particular. The public health people were raising the importance of doing this and the GUM people were kind of putting their hands up, saying, "No, for goodness sake, don't do that because we won't be able to handle the amount of work we'll get arising from this campaign and this screening". That does seem to be an issue. Professor Kinghorn, who came before us in the previous session, I am sure you will know of his work, said that an education campaign, if it did not go hand in hand with capacity increases, would drive already overstretched services to a state of collapse. Could you outline the planned timing of the campaign and how you are taking account of that anxiety that the campaign needs to be linked into being able to deal with the demand you are going to generate? Miss Johnson: Well, that is an absolutely accurate analysis, that we need to be careful about that. Obviously the investment is now going out and to some degree there are issues around facilities, although we have also made investment already, some additional investment on the capital side of things, so there is some additional historical capital investment gone in. On the service side, we obviously need the service to be able to respond. We are thinking at the moment about the design of the campaign and we are in the early stages of doing that. One of the things we need to do is to raise awareness of the risk and a part of that is preventative. It does not necessarily have to lead only to people thinking, "Ah, I might have a sexually transmitted infection. I had better go and get checked out or screened", so there is an element, a very big element probably actually, particularly as for each new age group coming through, the sort of 19 to 25-ish greatest period of being at risk, as it were, there is a particular need to educate them, so we have got to get the balance right, you are absolutely right, between educating and information and using that as a preventative tool and simply stoking up demand, some of which may be the worried well as well, so we need to get that balance right and that is what we are thinking about in terms of the campaign which we will be running later on this year. Q160 Chairman: Do you think there are any lessons which can be learned from the AIDS campaign in the 1980s and 1990s? One of the areas that we recognised was a problem was that in the 1980s and 1990s the public were much more aware of what AIDS could mean and many of us knew people who had died of it, let's be blunt about it, and the AIDS campaign at the time, the education campaign, was pretty explicit. Miss Johnson: Yes, I remember it. I am old enough to remember it! Q161 Chairman: Yes, I know how old you are! It was your birthday, I saw it in the paper and it mentioned your age! What I wondered was whether we have learnt any lessons from that and will we recognise the need to be pretty blunt and pretty explicit and to talk in terms that kids understand as part of this campaign? Miss Johnson: I think one of the things that we have done historically is to target the 18-to-24 age group. I think that everybody accepts that we need to target a wider age group really and I think that one of the features of the HIV campaign, the tombstones campaign, was actually that everybody became aware of it and I think there may be a need to make sure that everybody is much more aware rather than us only targeting the most at risk in the population. I think we also need to do more about actually working with young people before they get into that age range so that they are aware of the risks too. In a sense, although obviously we would not want to return to those days in any way, it was easier to scare people about HIV when in this country people were dying of it regularly and although people still sadly die of it, in a lot of cases their lives are very considerably extended and, who knows, even indefinitely, as it were, by the complex drug treatments that are now available. I think we have to reckon that it is going to be a little bit more difficult to worry people on that score, but we are already running sexually transmitted infection campaigns which are aimed to frighten and make people aware and to lodge it in their memories, to use good handles for doing so and to make sure that they really do register in the minds of those that we are targeting at the present time, and we need to make sure that we extend that effectively to a wider group, I think. Q162 John Austin: The Chair mentioned earlier the study you have commissioned from the Medical Foundation for AIDS and Sexual Health, which is something which we would welcome, but I know that that is a two-year study. Miss Johnson: Yes. Q163 John Austin: But the first phase is complete and you have the results. Miss Johnson: I have not personally had them to me with advice from officials as yet, so we are very happy to share them with you in due course. Q164 John Austin: The results of that study do give the most accurate, up-to-date snapshot of how GUM services are functioning. Miss Johnson: Yes. Q165 John Austin: That information is available. You may not yet have seen it, but it is in your Department. Miss Johnson: Yes, I am sure that it will be with me soon. Q166 John Austin: Your officials may not have had a chance to interpret the findings, but the findings are there. Miss Johnson: But that is the case, that normally there is a process of digestion really in any government department when it goes through looking at things. I think what we have got is--- Q167 John Austin: But would not the most up-to-date information available be very useful to the Health Select Committee in conducting an inquiry into the state of the sexual health services in the country? Miss Johnson: I do not know without looking at the information. I am not sure that the picture is going to markedly change. I think we have all got the broad idea about what the picture is and I am sure you are very well aware of what the picture is actually, so I do not think that this is an area where there are likely to be dramatic changes one way or the other. I think what the MedFASH survey is is an ongoing audit of individual services, as I understand it, and actually what we will do at the end of that is we will get an overview at the end of two years about what the picture is out in the field. Obviously I believe that the teams are communicating back, as they are out there doing the audit work, the results of their work, as it were, back to the places that they are looking at. I understand that that is going on, but I am not familiar with the detail of it. I do not know whether Geoff would like to comment on the process of the review. Q168 John Austin: Perhaps he might be able to tell us when the Department received the data and how long it will take to interpret the findings. Mr Dessent: We received the data quite recently and, as the Minister said, what we would normally do is look at that in the context of all the other information we have got and then put it to the Minister so that we can decide how best that informs the study and indeed as to whether there is a case to release stuff earlier rather than later in terms of informing where we are. Q169 John Austin: How recently is recently? Mr Dessent: Well, I was only aware of it a few days ago. Q170 John Austin: Perhaps we might find out later how long you have had it. Miss Johnson: I think that was a few days, but we can give you a precise date. Q171 John Austin: It still does strike me that it is rather curious that there is this air of secrecy about the raw data which, if one values the work of Parliament and scrutiny, the Health Select Committee and its report, it would seem sensible for the Committee to have the most up-to-date information, would it not? Miss Johnson: It is normal practice in fact. Firstly, this is a rolling snapshot, so there are some questions about getting to the end of the business of taking those snapshots anyway and having the whole film, as it were, and that is one issue. The other issue is that it is a series of snapshots. I think it was only as a result of something said to the Committee that we really became aware that there were things emerging from the findings, so actually you knew about some of that, as it were, or were told about some of that before we were. We were the commissioner of the data, but actually the data has only just come to us on the back, I think, of what had occurred at a previous hearing or what was said to you in some way or another by way of briefing, and I am not quite sure which it was here, so it is not any attempt to keep anything secret whatsoever. As I say, I doubt very much if it will fundamentally alter the problem that we are facing. I think we all understand very well what the problem is that we are facing and what the main things are that we need to be doing to address it and that is why we have got the course of action that we announced in the White Paper and why we are pursuing that through the funding announcements of yesterday and the problem is very well known. Q172 John Austin: But the information contained in there, which is somewhere within the Department, will at least be able to tell us whether services are about the same, improving or deteriorating. Miss Johnson: Well, the 48-hour target monitoring is also being conducted every six months, so we will get a second read-out on that shortly too and we will certainly be publishing that. Q173 Dr Taylor: Minister, can I go back to the funding issue to try and sort of tease out some of the details. In your very helpful paper, you have summarised the money that comes from the White Paper, which is the £50 million over three years for the sexual health campaign, the £130 million which you have already mentioned, £80 million to help with the Chlamydia work and £40 million to help with the contraceptive work, so that is the £300 million. Miss Johnson: Yes. Q174 Dr Taylor: Yesterday the Secretary of State announced the amounts going to primary care trusts and in round figures, from memory, because I have not brought the paper with me, if a primary care trust was getting, say, about £120 million and an average rate of increase is about 10 per cent on last year so that means the increase is £12 million, is that £300 million or a PCT's share of that £300 million part of that total increase or is it on top of it? Miss Johnson: I think it is part of that total sum of money, although the percentage you are quoting I think is a one-year percentage because I think the 10 per cent or thereabouts is the average for 06/07 and the following year has a similar additional percentage increase on the budgets as well, so they will vary between sort of 8 and 13/14 per cent on each of those years, roughly speaking. Q175 Dr Taylor: So working on very rough round figures, if a PCT that has got an increase of 10 per cent in fact has got an increase of about £12 million, that is to cover absolutely everything in its local delivery plan? Miss Johnson: That is correct. Q176 Dr Taylor: Is there any compulsion on what is in the local delivery plan? Miss Johnson: Yes, that is what I was saying earlier on in relation to what the Chairman was asking me, that is to say, that the local delivery plan has to include coverage of how they are going to meet the sexual health needs of their population and they will be assessed on their performance against that and their delivery of that as part of the delivery plan, as part of the performance management that is undertaken and as part of the Healthcare Commission work on monitoring them, so for the first time ever in fact there will be a demand that they deliver, as it were, in outline on sexual health. Obviously the exact nature of what goes in there needs to reflect local needs and local circumstances and that is entirely in line with our policy, that you need to get it local and the decision-making local. Then on top of that there will be the normal performance management of that and account taken of the delivery of it by the Healthcare Commission. Q177 Dr Taylor: So even though there is not an NSF or particular NICE guidance on this, there has been compulsion on them to put this in their local delivery plan? Miss Johnson: Yes, it is a strategy, and I know we have had this discussion many times, but the strategy is not very much different from actually having an NSF. Q178 Dr Taylor: You have already touched on the fact that we have doubts. If the money is given direct to GUM clinics, it gets there, but if it is given to PCTs, it tends to sort of leak out. Are you really quite confident that this method will spot that it really is going to what it is meant for? Miss Johnson: Yes, because we have never had this degree of performance management on sexual health provision before and, coupled with the monitoring that we are doing now six-monthly on the 48-hour target, the extra investment that is available which was not available for them before, both the overall quantum of investment where the envelope is much bigger and much more generous on top of historical generosity, as it were, and they have already got a lot of investment gone in historically, they have got a very large extra increase which has just been announced for 06/07 and 07/08 and, within that, there is specific money which we are expecting them to deploy for this purpose and on which their performance will be monitored if they do not deliver it. I think also, as it happens, that the public anxiety around this subject, the attention that the Select Committee has given it, the House has given it, we, as ministers, the Department are giving it and the Government is giving it is sending a very strong message in any case to commissioners that this is more important than they may have thought it was historically and that will be reflected in changed behaviour on its own, but, on top of that, there will be these much more formal and much more fierce, if you like forms of monitoring and performance management. Q179 Dr Taylor: I am absolutely sure we all welcome this huge amount of money going in, but has there been any estimate of the cost of local delivery plans in total? Again I am speaking sort of locally. I know that local PCTs have debts and overspends amounting to several million which will mop up the first bit of their extra money. Is there any assessment of what a typical PCT's local delivery plan would cost if they funded everything in it? Miss Johnson: Obviously we have sent out money, having had some look at the centre at what that money is going to be spent on and how reasonable that is, what the pressures are, salary increases and other structural changes which may lead to them needing more money for things, so we have looked at all of those demands and, within that, the plans have been formulated and the money has been allocated. The money, as you know, is also for the first time much more closely correlated actually to the needs in a given area, so there has been a much greater focus on getting more money to those areas with the greatest need and some of those needs will be reflected across the board and will impinge on sexual health needs too because some of the areas with the greatest deprivation are probably some of those areas with the greatest sexual health needs as well. Manchester, for example, with £113 million extra going into it has got, we know, a number of needs on this front and it has a number of other health needs, so we have got all of that background to this. You asked me something else as well, I think. Q180 Dr Taylor: Firstly, perhaps I could follow that up. Would it be possible if we, as a Committee, or I, as an individual MP, put in a PQ to ask for a list of all the PCTs' costs of their local delivery plans? Miss Johnson: No, I do not think that is possible because the local delivery plans are formulated by them. We have looked centrally at what we think the needs of the services are across the country. We cannot divide that up against the local delivery plans. They will cost out their own delivery plans. I know what I was going on to say. You mentioned deficits, but historically the Health Service has been in financial balance over the last four years, so this position about deficits is a bit of a moot point and at this time in the financial year the apparent deficits always look rather worse than the outturn at the end of the year as well. I think because it is such a moving picture, it is very difficult to be clear about this, but we regard the money that went out yesterday, including this money, as additional money, not needed to meet any so-called deficits and actually available for the improvement of services and access and all the other things that we have been talking about. Q181 Dr Taylor: So the only way for us to find out the cost of each PCT's local delivery plan is for each MP to contact their own PCT and find that out? Miss Johnson: Well, I assume the cost of their delivery plan will be their budget. They have got a sum of money and in order to deliver that, they will be producing a delivery plan actually to meet up with the budget that is available to them. Q182 Dr Taylor: I would have thought that the development of a local delivery plan goes through a process before that. You decide what you want and the cost of that and then you have to cut that down to the money that is available. Miss Johnson: This is a normal process at all levels of anybody controlling any expenditure in any arena of life. I think we would all wish to have fantasy sums of money available to do all sorts of things which we are never going to be able to do, so I think we have to accept that we would all be able to sit around and think of things that we could do with more money, publicly or personally, but that is not the reality of the world. There are record sums of money going out to the Health Service. The increase has been absolutely phenomenal in Health Service funding. Q183 Dr Taylor: No, I am not arguing with that and I am clearly not thinking of fantasy either, but I can see a picture where the demands of sexual health services are possibly at the bottom when they are pitted against the demands for developing cardiac surgical services and cancer services. That is all I am trying to get at. Miss Johnson: In the days in 1997 when there were 18-month waits for hospital inpatient treatment for some people, there was a lot more difficult weighing up of priorities to be done, whereas now our aspiration is to get to 18 weeks from start to finish of that process and where we are already under nine months and will be under six months by Christmas, so of course there is always a weighing up of priorities. Everybody has to weigh up priorities. The Government has to weigh up priorities. Whoever you are, you are weighing up priorities, but I would say that having been a local authority member in difficult times in the 1970s, 1980s and 1990s, actually I know that those difficult decisions were actually in the arena of cuts and actually where you cut, not where you expanded and how much you could expand. There is a very different climate for people running the services today in the public from what there was in, say, the late 1980s or early 1990s. Chairman: You talked about the mechanisms that you have put into place to ensure that the funding is actually spent on the purpose, and we welcome that and want to see some positive outcomes. One of the things that really caused me concern when we looked at sexual health was the way in which the service in some areas was so substandard that I think all of us were shocked at what we saw. What we were trying to establish was how that could happen, how it could be that those organisations responsible for that service had allowed that service to deteriorate to such an extent that some of the facilities were, frankly, appalling. Obviously we came to some conclusions, one of which was that this is an area which is, and I was going to use the words, "not sexy" ---- Miss Johnson: Yes, I do know exactly what you mean. Q184 Chairman: It is not an issue that you or I, as local MPs, would get constituents writing to us about. Therefore, politically we are not under pressure to do a lot about this area. In the context of the move towards devolving decision-making, and I personally support the direction the Government is going in, how do you square that problem that possibly in certain areas they will not want to make, as Richard says, investment in this area because it is not something they are under pressure to do, how do you balance that with trying to reduce the amount of central directives which to some extent you have just described and how do you square that up with devolving the power to local people and letting them make the decisions in their own back yard? Miss Johnson: Well, there is always a balance to be struck, is there not, so, for example, we have taken the decision that there are improved tests available for Chlamydia, that we want those tests rolled out, that we want a national screening programme, that we are going to have that, that that is going to be put in place, that resources have been deployed behind that investment and that that is not a matter for local decision-making, as it were, and that there is going to be a national campaign because we think campaigns need to be run nationally rather than regionally or locally, although they could be backed up in that way, so some of those things need to be done on a national basis. Some of the frameworks, some of the demands and standards and the monitoring all need to be done nationally and, within that, I think we want to devolve as much as we can to a local level. I agree with you that I think historically sexual health and particularly the clinics themselves have been a forgotten area and they have certainly not been sexy, in the way that you are saying, and it is exacerbated by the fact that people do not write to us, complaining that they had to attend the clinic and how appalling it was or whatever historically. It has now come, I think, very much to everybody's attention that more investment needs to be made and that is why we have made the investment. We need continually to monitor that, but I think for the first time now as well that the commissioners of those services, and we have to remember historically that a lot of what we are dealing with goes back many years and indeed the Portakabins or whatever go back many years as well that it was taking place in, or still is in some areas, actually it was not the PCTs commissioning in those days. They have got sexual health needs now in the PCTs, we are building networks for the sexual health needs, we are doing more to look at information about training sexual health workers and we are doing a lot of things to support the service, to network the service and to make the commissioners much more aware of the demands on them, plus the formal performance management side of it, which I went through earlier on and I will not repeat again now. Q185 Dr Naysmith: In evidence to this Committee Dr Ford Young, who is a general practitioner who has a special interest in sexual health, told us that in the area of sexual health there had been a great missed opportunity when the new GMS contract was being negotiated. Do you share that view? Miss Johnson: No, I do not. Why did he feel that because that was a statement, it was not a set of reasoning? Q186 Dr Naysmith: Well, one of the arguments he had was that the essential services element of the new GP contracts should have included sexual health and that there would have been an opportunity there to take all sorts of steps that there is no incentive to take now for GPs. It is not incentivised at all under the new GP contracts, that GPs should involve themselves in this sort of area, and there are lots of things that GPs could do in this area. Miss Johnson: Well, PCTs can contract in a whole variety of ways for this. They can use a lot of the medical contracting routes available to them from general practice sexual health services which can be tailored to meet needs using various different routes, the GMS route, the PMS route, the alternative PMS route and the PCT-led medical services, so there is a whole lot of avenues there that are open for contracting purposes, and there is the enhanced services aspect as well, so there are a lot of ways in which sexual health services can be delivered and practices indeed are continuing to offer consultations and examinations and so forth as well. Q187 Dr Naysmith: Apart from all these acronyms, you obviously said that the PCTs "can". Miss Johnson: Well, I have already dealt with the issue about what the pressure is on the PCTs and I hope it is clear that there is a lot. Q188 Dr Naysmith: I know, but the argument was that this ought to have been part of the essential services because, as you know, the essential services are things that PCTs must do. Miss Johnson: Yes. Q189 Dr Naysmith: Infections, and some of them can be life-threatening infections, should be treated, should they not? Miss Johnson: They certainly should be treated. If they are ill, they certainly should be treated. Q190 Dr Naysmith: Instead of just saying, "You've got to go down to the Portakabin down the road." Miss Johnson: In fact, the vast majority of these are not life-threatening, although they are things that we want people to be treated for. They are mostly one course of treatment, as I know I do not need to explain to you, with the exception of HIV/AIDS. Q191 Dr Naysmith: So what you are saying is that syphilis and gonorrhoea, both of which seem to be on the increase in some parts of the country, are also life-threatening diseases, as well as AIDS. Are you saying the Department is quite happy with the situation and does not intend to review anything to do with the GP contract? Miss Johnson: I am sure over all we will be looking at the way in which the GP contract is working, but it is not to say that we anticipate any formal reviews, including formal review in this particular area. Q192 Dr Naysmith: What steps can PCTs take then to incentivise GPs to undertake some of this work? Miss Johnson: They will be the commissioners of service, so they are in the same position as really anything else. If local GPs do not want to offer a number of services now, they are not obliged to offer them. The PCTs, however, have the money and the money follows services, as it were; it follows the patient. This is increasingly going to be a powerful tool in the Health Service, I believe, for delivering the quality of services we want, delivering the access that we want and we should get, and also being able to use the money flexibly to deliver that in a number of settings. In this particular case, I think the role of the clinics is very important and we want to see the clinic provision maintained, with a better quality and better access, but equally well, there are a number of other avenues. We have recently been going out to tender on some publicity on some of the Chlamydia testing arrangements, and there are opportunities for some of these services to be provided in a very different way in the future, a way that I think will suit the generation that we are particularly focusing on, and a way which will make it more tailored to people's everyday lives and what suits them in terms of ease of access, timings, and so forth. Q193 Dr Naysmith: Mr Bradley is going to ask some questions about Chlamydia in a minute or two, but this is an absolutely obvious area, because there is evidence that large numbers of GPs, maybe as many as 50 per cent, are interested in providing Chlamydia, but at the moment there is no incentive at all; there is no reimbursement for GPs under the current circumstances for doing it. Are you saying GPs are going to be allowed to be part of the bidding process to provide Chlamydia screening? Miss Johnson: We have arrangements in process for rolling out the testing for Chlamydia screening. We have not got through all the detail of how that will be done at the moment, but the aim is to get all of the Chlamydia screening across all of the strategic health authorities by April 2006, so we want to have all of that screening in place. The GP does not have an incentive to treat me particularly when I turn up with whatever everyday complaint there is. I am not quite sure... You know, they are paid. Q194 Dr Naysmith: They are paid to diagnose and send off to consultants where it is something tricky and they want a second opinion and so on, but there is quite a lot of sexual health which can be treated in primary care, and there is no incentive in the contract, we were told, at the moment for GPs to do that. Perhaps we could ask Mr Dessent if he knows - obviously, with your permission, Minister, since you are in charge of that end of the table - whether when the contract was being negotiated the area of sexual health was considered as something that might be included in essential services. Miss Johnson: Before he makes any comments on that, can I just say there are a lot of different providers who are clearly very keen to provide, and when you say GPs can obviously do this, obviously GPs can, and we hope that they will continue to do so, but we are looking for a mixed economy so that there is a variety of patterns of provision that both meet the individual needs of that particular community, as it were, rural, urban and all the rest of it, but also meet the needs of different sections of the population. For example, community pharmacies may well be one route in a community setting. The GP is one community setting alternative for the provision, but it is by no means now the only alternative, because clearly, there are a whole variety of other forms of provision growing up, which are increasingly very well supported by the public and which they find very convenient and which we want to increase where that is appropriate. Q195 Dr Naysmith: I do not know if Mr Dessent wants to answer the question, which was not just about Chlamydia but about general sexual health services. Mr Dessent: Obviously, in terms of the development of the GMS contract, yes, of course we were involved in discussions about that, and made the case for where it might be introduced. I probably should say that there will be at some point a formal review of the GMS contract, and we will be making those same arguments again to see whether there are particular avenues that might be explored that would start to address some of the points that you are raising, and certainly Chlamydia is one of the issues that we particularly recognise as being relevant to this. Miss Johnson: We will have at that point a lot more provision on the ground than we currently have, and it would be interesting to see how that is developing. Q196 Dr Naysmith: The other thing, changing the topic a little bit, is that if we are going to have these increased services, there has to be an increase in the amount of training that goes on. Miss Johnson: Yes, indeed. Q197 Dr Naysmith: It has been suggested to us that, if we are going to have this increased capacity within primary care, GUM clinics and contraception services as well, we need a separate training budget and a formal national training programme for doctors and nurses, both at the pre-qualification level and the post-qualification level. In particular, it was suggested to us that GPs and practice nurses have a pressing need for training in this area. Are you aware that there is a problem, and do you have any plans for addressing this? Miss Johnson: It is quite interesting, because, as you know, we have recruited about 80,000 extra nurses over recent years to the NHS as a whole, and what I have been quite struck by as I have gone about my travels is the number of people I meet in primary or community care settings now who are ex-hospital. They may be cardiac nurses, now doing cardiac rehabilitation in a community setting, when they were formerly working in the cardiac units in the DGH or whatever, or other people who have moved out to provide other services in other settings. I have come across quite a lot of these people in treatment centres, in the community, working for GPs, working in out-reach work. I am not sure what the work force patterns would show but my suspicion would be that there might be a bit of a drift of people from acute settings, with a lot of very relevant experience, now providing an allied or very closely related service in a community setting. But, of course, because we want more provision in the community, we do need more work force in that area. There are work force planning arrangements, and strategic health authorities have a role in this regard. I think in a lot of communities growing people on through roles in the NHS and allowing them to get qualifications is a very important part of that. I met somebody working in mental health, who was responsible for a unit, who had started off as an untrained nurse and had been allowed to go off as part of that and get the training, and then return to the unit. This is where it is having advantages for those communities, that people are being skilled up by the NHS, who are a major local employer in many settings, and particularly in areas where employment options are still not as rich as they may be in other parts of the country. I think there are a lot of avenues there. On the sexual health side of things specifically we have... Q198 Dr Naysmith: A lot of the things that you have just been talking about have involved specialised training for these nurses and doctors in the NHS, and we are saying we need it in the sexual health field. Miss Johnson: Yes, I am just going to answer that point. We have actually undertaken a mapping of training needs and produced some recommendations and an action plan on that. There has been a day held with stakeholders which led to a national working group - this is on training - being established in partnership with the Centre for Sexual Health in Sheffield, so I think this is very much meeting up with the point you are making, and its terms of reference are to do things like take forward the action plan for training, agree quality standards, make sure there is consistency in training - this is for sexual health professionals - and to work towards national accreditation. There is a distance learning package as well for nurses, that has been published and accredited by the University of Greenwich, and there are also some key competencies published for sexual health nurses. I think increasingly we are looking at diversifying our work force and giving them specialist skills in particular areas of provision. Sexual health is probably just one example of that, and I think the wider skills mix that we therefore need is something which, across the Health Service, we are having to address, but in this particular way we are addressing it like this. Q199 Chairman: Before we move away from training, I mentioned that last week I had visited this sexual health project in my own area. It is a West Yorkshire-wide sexual health project. I asked them about the use of primary care, saying that one of the things that the Committee felt was that we could make more use of alternatives to GUM within the community. You have mentioned pharmacies. I certainly felt that GPs could probably do a lot more than they do now. Their response, particularly from the perspective of dealing with lesbians and gays, was that they had had some very negative experiences. The local service co-ordinator faxed me subsequent to the meeting to say the reason he would always direct to a GUM clinic - that is, his clients - is completely due to the number of poor consultations that service users have experienced at their GP's. I think he is talking of West Yorkshire, not just my own area. He gave me one or two examples of quotes given to him by users of the service. One young girl was told, and I quote, "You are too young to know you are a lesbian." This is, obviously, a GP, according to the person. Another girl was told "You are gay. Have you had any counselling?" A young man who used the service said, "I told the doctor I was gay and he immediately wrote 'HIV?' in my notes." What they are saying to me is that there is a need for training of GPs to include not purely medical screening, STI screening or whatever, but sexual health consultation, which in their view in many instances in my part of the world is done rather insensitively. We might be an exception to the rule, and I suspect we are talking about a minority, but would you feel that this kind of area could be addressed in looking at the training needs that Doug has referred to? Miss Johnson: I think that is a bit different because if you are talking about training of GPs, that is really a matter for the curriculum; both the initial curriculum and post-graduate training is really a matter for the Royal Colleges. They are in charge of a lot of what happens on all of that, both the nature of it and how it is delivered as well. We obviously do have dialogue with them about training, and various parts of the Department and through the Chief Medical Officer, we have links into the Royal Colleges and what they are doing, but it is a matter for them, and I think it would probably be most useful to discuss those issues with them. Obviously, we are always concerned if GPs are not giving patients an appropriate response, and I take it that the PCT may be interested to know that and may want to pick those issues up with some individuals or some practices themselves in an informal way. Chairman: These may be isolated examples, but, as I am sure you will appreciate, if that is the kind of response you are getting, it is not exactly encouraging a person to continue using the Health Service when they may need to. Q200 John Austin: Can I just come back to something on the GP contract and GP services in relation to contraceptive services? The FPA in their evidence suggested that the GP contract's lack of quality points for the provision of contraceptive advice undermines this aspect of the contract and does not incentivise general practice to provide a comprehensive contraceptive service. They have also raised concerns about the introduction of PBR, payment by results, and suggested in the area of contraception, as an example, it could militate against the provision of longer acting contraceptives in favour of repeat prescriptions of oral contraceptives instead. Would you accept either of those criticisms? Miss Johnson: I would have no reason to believe that, but I would be happy to write to you on the second point. On the first point, we have recognised through the White Paper and through the investment that is going in that we do think more investment needs to go into contraceptive services. That is why we have an audit of what contraceptive services are available going on, and that is why we have already made £1 million of investment anyway this last year to improve contraceptive services. There is £40 million additional being supplied to address gaps in the service on the back of the audit that is being undertaken. We have also established a group to develop an action plan for improvement to the services, so there is a nice guideline being developed on long-acting methods of contraception which we think will raise awareness and usage, and we have also allocated money, £200,000, to support nurses to undertake the distance learning programme specifically on contraception. That will train 2,700 practice nurses in basic sexual health skills and supplying of condoms and emergency contraception. There is a range of provision going on. I think we do need to see improvements in contraceptive services, and that is why we identified the money to do so. Q201 John Austin: So the audit will include general practice contraceptive provision as well as family planning clinics? Miss Johnson: Yes, yes. Q202 Mr Bradley: Minister, can I go back to Chlamydia screening? You have made some comments already on it. We have had evidence that 45 per cent of Chlamydia tests are still being performed using the suboptimal test. Can I take it from your previous answer it is the intention that the NAA test should be applied in all cases by April 2006? Miss Johnson: Yes, that is the intention, because the other test has many more false results on it, particularly false negatives. We do not want to continue to use it longer than we have to, but obviously people need to be trained, the facilities need to be there to use the new test, and staff need to be trained in doing so. It is like any of these changes on national screening; you have to have a roll-out period, unfortunately. Q203 Mr Bradley: That roll-out period is April 2006. Miss Johnson: Yes, that is the aim, to get 100 per cent coverage, all the strategic health authorities involved by that date. Q204 Mr Bradley: Secondly, therefore, if we are going to have a national screening programme, it should apply to all ages and both sexes. You are obviously agreeing with that, so why is the current emphasis on women under 25s and not men? Miss Johnson: It is not, actually. In the interviews I have done myself in the last few days I have been emphasizing young men as much as young women. Obviously both sexes are infected, otherwise the problem would not be there at all. We need to make sure that both sexes come forward. In fact, we have specific screening programmes running around prisons and also MoD facilities, so there is some specifically targeted largely at the male population, but we want to see both sexes come forward for screening. I think the risks are broadly the same for both of them. I do not think there is quite so much evidence of the infertility for males but there is still evidence of a serious risk of infertility there, as there is quite a lot of evidence that it has that consequence for women and, because it is asymptomatic, we are very concerned that people are tested, and it is so easy to get treatment. Q205 Mr Bradley: So the campaign, when it is launched, will cover the whole spectrum? Miss Johnson: It certainly will, yes. I think one of the things, again, about making facilities available: young men are not frequent attenders at GPs, for example, and unless they have had a need to go to a clinic, are they likely to necessarily know where their clinics are? They will know where things like pharmacies, etc, are so we need to think about the locations where people are going to be. We need to look and see as well whether we can run screening through colleges, for example, and other areas like that where a lot of young people may be gathered in the relevant age group at the same time and do things on a much wider scale. Q206 Dr Naysmith: I just wonder, as well, Minister about the concentration on under 25s, simply because there is a lot of anecdotal evidence - I do not know of any really hard evidence - that people are sexually active to a much later age. Miss Johnson: Considerably later than 25, probably. Q207 Dr Naysmith: We know that Chlamydia is sometimes used as an indicator of other potential hazards and risks being undergone. Is it wise to concentrate on the under 25s? I know it is because of the fertility aspect, but is it wise to concentrate on the under 25s and not have a general screening programme? Miss Johnson: I think that goes back to the question about the national campaign to a degree, and I agree; I think we need to extend the range that we are covering. It really does go up to about 30 though, the age groups that we are targeting through magazines and holiday-related publicity, pubs, clubs and all the rest of it. It has picked up up to the 30s. But the reason for targeting Chlamydia is because there has been a massive increase, because people are unlikely to know they have it, because about one in nine or ten sexually active young women is infected with it, and probably a similar number of men, and what we wanted to do was to actually raise awareness of it, so that people did not think "Chlamydia" was some unusual women's name. There was a degree of ignorance about it at one stage which meant that everybody had heard of gonorrhoea or syphilis or HIV/AIDS and not everybody apparently had heard of Chlamydia, and because there were not the symptoms, I think it was right and it is right to focus quite a lot of attention on it. But of course, if they come forward for testing on one thing, there is much more chance that if they have other, related needs, those needs are going to be identified and dealt with too. Q208 John Austin: I am just curious. Despite the recommendations in our report, your White Paper does not mention abortion services at all. Is there a reason for that? Miss Johnson: Our White Paper does not mention an awful lot of things actually. It was focused on the areas where we could principally change behaviour by a mixture of support, provision and education and information; an informed choice, as it were. There are obviously a whole lot of very difficult issues around abortion. There has been much discussion of it. It has always been a matter for Parliament to decide what happens with the abortion laws, and a lot of the provision around it. We have certainly concentrated a lot more money on contraception, which I think is the right area to put a lot of extra investment in. We decided to leave many things out of the White Paper. It would have been a huge document had we included everything that technically belongs to public health. Q209 John Austin: Abortion is clearly a key area within sexual health services. Will it feature in the implementation plan? Miss Johnson: No. The implementation plan is focused on what is in the White Paper, so it will focus on sexual health, where we have already made announcements, so everything from contraception through to the national campaign for clinics, screening and Chlamydia and so forth. As far as I am aware, we are not planning to have any provision or any particular reference to delivery on abortion in there. We have focused on improving early access to abortion and we have succeeded in improving early access to abortion. It is a matter of personal view but I personally think it would be much better if we succeeded a lot more on contraception. Q210 John Austin: Can I go on to a complete different area, charging for HIV services? There are many statements in the media, and I believe one of your colleagues in the Department has suggested that there is a high level of health tourism. In particular, there has been reference to HIV tourism, but I am not aware of any substantive research that has ever been carried out, and the evidence from organisations like Terrence Higgins that we have received would suggest that HIV tourism is a bit of a myth. Miss Johnson: It is very difficult to produce figures. Historically, figures have not been collected by the Health Service, over decades - never, basically - about levels of people using the service who are not resident or normally resident in the UK. That is partly because, obviously, some of the people who use those services are genuine tourists - and I am not just talking about HIV/AIDS here; I am talking more generally, because it is quite difficult, again, to make distinctions between this and a number of other things for which people need treatment. It is impossible therefore to disaggregate data as to whether a tourist came over and broke their foot and received treatment through an A&E department or whether somebody came in and received another service as a so-called health tourist. Q211 John Austin: The evidence seems to suggest that people who have come into the country with HIV actually seek treatment late, which seems to suggest they have not come here as HIV tourists. Miss Johnson: Yes. I do not want to join in your conjecturing. I do not have any figures to supply you with on this. I concur with the point that it is difficult to measure it, and we do not have reliable information. What we are clear about is that there was some abuse going on of the existing rules, and that is why the rules review was undertaken, and a tightening up of the wording to deliver the same consequences that the rules had almost all been intended to deliver before. There has been very little change of substance on the rules, but what there has been is a tightening up of the wording so that they actually deliver the results that they were originally intended to deliver when they were first devised. Q212 John Austin: I will come on to that in a moment, but you are really saying there is not any evidence that the UK is likely to become a magnet for HIV tourists? Miss Johnson: What is clear is that if people think they can come in and, under any circumstances, remain here for free treatment, we would become such a magnet, and that was what we were concerned to deal with. We are a national health service; we are not a global health service. We are here for people who are resident, and residency is the basis of the entitlement here, as defined normally by many of us here, permanently resident, but there are a number of other categories of people who count as ordinarily resident here for these purposes, and we have made sure that those categories are very clear in the revision that has taken place, because we did not want the wrong messages to go out elsewhere. Q213 John Austin: Let me come on to the rule changes and let us deal with the removal of the 12-month exemption. In the past, persons who have been here for 12 months, even if they no longer had proper authority to remain, were allowed treatment, and now that is not the case. That would include, of course, over-stayers and maybe failed asylum seekers, some of whom may well at some stage, through an appeal process, be regularised and be lawfully here. Has the Government any estimate of the numbers of people who are now no longer eligible for treatment as a result of the change in the 12-month exemption? Miss Johnson: No, we do not. Let me be clear about a few things, because I think it is very easy in this area for people to get the wrong end of the stick on it. First of all, people who come here are entitled to free tests and, under any circumstances, somebody here, as they are entitled to free sexual health services, they are entitled to free diagnostic tests, and the initial response to that in terms of counselling, free on the NHS, and that includes anybody who thinks that they have HIV/AIDS. So there would be no reason in relation to any of these things why somebody should not come forward early; in fact, what we need to do is increase awareness so people do come forward as early as possible for testing. But when people are coming into the country, there is a lot of evidence that people do get tested. What we are doing is making sure that, when they are here illegally, they are not entitled to remain simply to get free treatment when they are illegal over-stayers. That goes back to the earlier point, that the basis of treatment has always been residency, and that means legal residency, and people who have simply over-stayed, however long they have over-stayed, do not become legally resident by over-staying. We did not really change that, in a sense. We just went back to the fundamentals of it, that it is residency, and that means legal residency, and therefore, being here 12 months or more does not qualify you under those circumstances for free treatment. Can I just make one other point? There is still provision for easement by individual clinicians under individual circumstances, and at the end of the day, the decisions are the clinician's; they are not for ministers and they are not for politicians, or for any of the rest of us. Q214 Chairman: You do not have an estimate of the numbers affected by this change? Have you access to anybody else's estimate as to the numbers affected? Have no voluntary organisations put to you the numbers that are affected? You have no knowledge whatsoever, no guesstimates? Miss Johnson: No, no. Obviously, people who are being expelled are a matter for the Home Office as well, so that is not an issue for my Department. Q215 Chairman: I appreciate that, but you are in contact with other government departments, obviously, and in conjunction with them, there has been no estimate from them as to the numbers that might be affected? Miss Johnson: No. Q216 John Austin: I want to come on to this question of testing. I acknowledge that HIV testing is free of charge to anyone, and obviously we encourage that, and most of the organisations working in the field are engaged in encouraging people to come forward for testing. But Terrence Higgins have suggested to us that, where we are talking about migrant communities, who may not be eligible for access to treatment, there is now therefore a reluctance to come forward for testing, and Terrence Higgins in their evidence suggested this was having a significant impact on their encouraging campaigns. Miss Johnson: There obviously is a difference. The free bit of it is around the public health risk, and the public health risk if somebody has another sexually transmitted infection is that actually, if we treat them, that risk goes down to zero. Actually, treating somebody with HIV/AIDS, unfortunately, does not reduce their risk to the general population at all. It is only behaviour change that alters that risk. Q217 John Austin: But it is part of the Government's policy to reduce the number of undiagnosed HIV infections in the UK. Miss Johnson: Indeed, and we are actively trying to encourage people to come forward for diagnosis, because it is only upon diagnosis that people know that they need to change their behaviour definitively, and they can access treatment free, many categories of people, all those who fit the ordinary residency or who are applying for asylum whose applications are being considered. For those who are not legally resident here, obviously, there is not an ongoing entitlement to free treatment. Q218 John Austin: You are not concerned then about the evidence form Terrence Higgins that there is a resistance to come forward for testing where there is no eligibility for treatment? Miss Johnson: We do not have any figures that show that. In fact, what I think the figures indicate is that there are more people coming forward for testing and for diagnosis, and that probably, as well, the improved health outcomes for people with HIV/AIDS as a result of the improved drug treatments are leading people to think it is more worthwhile making sure that they get tested early and they get put on treatment as early as possible because that is improving their life chances, despite having the disease. Q219 John Austin: I might want to come back to that later. I understand that, in the correspondence between the Committee and your Department, the Department has made no assessment of the likely cost or cost savings of introducing the changes to charges for overseas visitors. Is that so? Miss Johnson: I have already explained that there are no figures about the numbers of overseas visitors being treated. Q220 Chairman: You must have an idea of what it would cost for a course of treatment. That is the point we are making. We appreciate you cannot add it up and say there are so many thousands, or whatever, but individually what would it cost or save? If The Daily Mail rang up your office and you had to argue with The Daily Mail, you could make an argument that it is in the interests of this nation financially to treat a particular person, so that it does not spread to others and cost the NHS more money. Miss Johnson: Yes, but people who are here legally or who have started a course of treatment are actually entitled to continue with that treatment free of charge while they are here. Q221 Chairman: I appreciate that, therefore you must know the cost of that course of treatment. Miss Johnson: You mean the cost of an HIV course of treatment? It is an average of £14,000. It is somewhere between £10,000 and £18,000, depending on the patient, as I understand it, but the average that we use for costing purposes is £14,000 a year. Q222 John Austin: On the risk issue as far as the general public health is concerned, in the evidence in a previous session, one of the witnesses, Dr Evans, in response to Dr Naysmith, was talking about the onward spread of HIV, and saying that they have reasonable data showing that the spread of HIV was strongly related to viral load, that viral load rises with the progression of the infection, etc, etc, and therefore saying that any delay in coming forward and being diagnosed is therefore likely to increase the spread of infection. Miss Johnson: But there is no reason not to get a diagnosis, because the diagnosis is free. Q223 John Austin: The diagnosis is free but the treatment is not available. Miss Johnson: The treatment is available for all those who fit. We can have this debate but it is a balance at the end of the day. We do have to look at how we allocate the resources and what the balance is. To take a ridiculous example, if we were providing free treatment for anything for anybody, we could be providing a health service to the entire globe out of the UK. That is clearly not a sustainable position. Nonetheless, there is a balance to be struck on this, and the question is where do you draw the line in the sand? We have drawn the line on people ordinarily and legally resident in the UK, and they have to be legal residents here, or categories that fulfil that, such as an asylum seeker having their asylum application determined. Everybody is entitled to free diagnosis, but everybody in that category of legally resident is actually entitled to free treatment. Chairman: I do not think anybody under-estimates the difficulties of decisions in this whole area. We are not in any way arguing that this is an easy area to address; I am sure it is not. Q224 Dr Taylor: Going on with this theme, if I may, Minister, I think you said the decision to treat is always going to be the clinician's. Miss Johnson: At the end of the day, yes, absolutely. Q225 Dr Taylor: Even though the financial aspects for some people will have to be sorted out after the treatment has been started? Miss Johnson: Yes, that is correct. Q226 Dr Taylor: Have I got it straight that it is only illegal immigrants who will not be funded for treatment? Miss Johnson: Yes. It is people who do not fulfil one of the legal residency requirements, and there are a number of categories; for example, if you are working here for a UK-based company, and there is a whole series - I do not want to run through the whole list because it is about a page of people who qualify under different categories - such as students here not for foreign language course purposes. There are lots of different categories of people who are entitled to use the NHS in this way, but what we have said is that people who are no longer legally entitled to be here... Actually, just on the point of appeal, while your appeal is being considered, you are still entitled to the free treatment, so if you appeal on an asylum case, for example. Q227 Dr Taylor: But there could still be an appreciable number of people who are potentially infectious who are not getting treatment, and that must be a public health risk. Miss Johnson: Yes. That is my point about the HIV/AIDS. People remain infectious. It does not matter how much treatment they get. Q228 Dr Taylor: Although as soon as you begin to decrease the viral load, you begin to decrease the infectivity. Our attention has been drawn to... Miss Johnson: Yes, but it is not like having another sexually transmitted infection where a course of antibiotics will remove the infection from the body. Let us just be clear. There is quite a difference here. Q229 Chairman: Neither of your colleagues are medical experts, are they? Miss Johnson: No, they are not. Chairman: There are quite a few heads behind you shaking very vigorously. I do not think it is fair to press you on that. It is a very specific medical point. Q230 Dr Taylor: I was only going to draw the Minister's attention to the paper we have been shown from Taiwan, which showed that the government policy of providing HIV‑positive people with free treatment reduced the rate of HIV transmission by 53 per cent. That was in the Journal of Infectious Diseases. That is a fairly powerful bit of evidence that if there is an appreciable number of people around who are not being treated, there is a public health risk. Miss Johnson: We obviously want to treat people because it improves their life chances and their quality of life and their life expectancy. Q231 Dr Taylor: It protects other people. Miss Johnson: That is not the main reason for treating people. The main reason for treating people is to improve their life chances and their life quality, and the question is, how far do our responsibilities as a government extend in this regard? I do not want to argue. I am very happy to get the Chief Medical Officer to write to you on the question of viral loads and all the rest of it. I have not seen this Taiwan paper. I have no idea where the research was done or what health service setting it was done in, nor what the circumstances of that are. The fact remains that you do not reduce to zero someone's infectivity by treating them when they have HIV/AIDS. Dr Taylor: I think it is only fair to say we would like some of the medical background for that. Q232 John Austin: I just want to go back to costs. You have said there is no estimate of numbers or likely cost savings of the changes, but what we do know is that the cost of treating someone with antiretroviral treatment is around £12,000 a year. Miss Johnson: The average is £14,000 but I am not disagreeing with the broad, ball park figure. Q233 John Austin: We understand that, without antiretroviral treatment, the chances are that that person will become seriously ill and may well need admission to hospital, possibly presenting at A&E, where of course A&E is free, but they may require treatment in hospital. If it is a matter of life and death, an emergency, that person will be treated but will presumably subsequently be billed for the services. I assume in most cases they are likely to be destitute, so the NHS is going to have to write that off at the end of the day. Has the Department done its sums on this, as to whether the cost of providing treatment might actually be a cost saving to the NHS rather than a cost liability? Miss Johnson: It is probably lucky that none of us are the people actually treating the patients. It is up to clinicians to decide the circumstances under which they treat or continue to treat a patient. They are able to do so, and the easement provision in the regulations allows them to make those decisions and to continue to make those decisions. That was a very important part of the discussion around the regulations when they were revised. Q234 John Austin: The clinician may admit the patient and treat the patient, but the cost of the treatment is likely to be twice the cost of the antiretroviral treatment they could have been given in the first place. Miss Johnson: No, what I am saying is they can decide to treat the patient directly for HIV/AIDS if they decide to do so. That is a matter for them. The A&E attendances are free - of course, they are not free in one sense; they need to be paid for, but they are free to the patient and they are free whoever the patient is, under whatever circumstances. Q235 John Austin: All I am saying is that the cost of treatment for someone who is denied antiretroviral treatment, who subsequently becomes seriously ill, is likely to be a bigger cost burden on the NHS than actually providing them with preventative treatment in the first place. Miss Johnson: That is why it is a matter for the clinicians at the end of the day to decide, or it is one of the aspects why they should decide whether to treat or not. Q236 Mr Bradley: Can I just be clear on this? What you are saying is that, with that clinical judgment and the fact that it would be half the cost to give the treatment in the first place, that is a decision that you would support because the cost to the NHS is much less than a person becoming ill and going into hospital through Accident & Emergency, and then receiving the treatment? Miss Johnson: These decisions are made by clinicians. Q237 Mr Bradley: You are happy for that to be the case? Miss Johnson: I am happy for the clinicians to be making these decisions. I think it is right and proper that they make these decisions because they are in the best position to weigh these things up and to decide what the best course, the balance, is, taking into account both the patient's interests and wider interests in their decision-making. Q238 Mr Bradley: And since it is cheaper to have the treatment in the first place, you would therefore, just in cost terms, recognise that that would be a beneficial decision by the clinician if they had the treatment at the earliest opportunity? Miss Johnson: Every patient differs, every circumstance differs, and every clinician's judgment is for them to make. I cannot generalise about what is obviously a hugely diverse set of circumstances, and I am not a clinician. Q239 Mr Bradley: But you would want a consistent approach to this? As the Minister, you would want to ensure that each trust, each clinician, was dealing with people in this situation in a similar way? Miss Johnson: The rules set out the overall framework and provide the arrangements under which people are treated free of charge or not. They will be treated with a charge whatever, but free-of-charge treatment provides the setting in which that takes place, provides the fundamental rules, the fundamental entitlements, and gives people advice about how those rules are to be operated. If a clinician wants to discuss something with the overseas patients manager in their trust, they are obviously at liberty to do so. They can seek advice from that person, but they are free to make their own decisions about things. I cannot generalise any more than I can generalise about what a GP should do for any other patient and for any other particular condition, because it is a matter for the doctor concerned. Q240 Mr Bradley: But would you want to ensure that using the overseas patient officer is applying the test of eligibility consistently across the country? From your position, would you want to ensure that each trust, through that... Miss Johnson: Yes. Q241 Mr Bradley: You would? Miss Johnson: Yes, but that is an application of the broad rules. You cannot argue about consistency in an easy way about individual clinician's decisions. Q242 Mr Bradley: Do you monitor those decisions from the centre? Miss Johnson: There are guidelines. There is a set of guidelines. Q243 Mr Bradley: Do you monitor how they are being implemented? Miss Johnson: There are obviously regular contacts. Elizabeth Ryan might want to comment on the contacts that are had between the Department and the managers, but clearly, there is regular contact between the Department and those involved with actually overseeing the implementation of the guidance. Ms Ryan: As the Minister has said, we have issued very comprehensive guidance, which has gone to every trust, and which we know through our contacts with overseas visitors and managers is followed fairly closely. I and my team have regular contact with overseas visitors managers. We attend meetings of the overseas visitors support group that Pam Ward co-chairs. We have people telephoning us, seeking advice and so on, every day, so we do know what people are doing and we do know that, if a particular issue is coming up, we can be in a position to make sure that people understand what the correct procedure is. Q244 Chairman: Would the kind of people ringing you be an individual GP or a PCT? Ms Ryan: It is usually overseas visitors managers themselves, the people who are actually operating the procedure, but yes, we have telephone conversations with members of the public, and I have spoken to one or two GPs, yes. We will talk to anyone who wants to seek advice from us. Q245 Dr Taylor: What bothers me, as an ex-clinician, is, with the clinical freedom, you start the treatment. Then the patient finds that they are one of the people who are not covered. Is there not a huge risk, when they discover the sort of bill they are footing, that they are going to just defect and not turn up and therefore stop treatment, and then they will be in an even worse state than before? Miss Johnson: I am sorry. The circumstances were not clear to me. You say that they suddenly find out. I am not sure what that amounts to. Q246 Dr Taylor: When the doctor starts them on treatment, does he say, because he has worked it out, "I am starting you on treatment but you are going to have to pay," or is that something that suddenly dawns on the patient later, so that when it dawns on them, they realise they are running up a huge bill that they can never ever afford, so they just stop the treatment and disappear, and then become another pool of infection? Miss Johnson: If they are seeing the doctor in the first place, the doctor has presumably become aware of what their residency entitlement is, as it were, and therefore whether they are entitled or not in the first place. You are not talking about somebody coming in through an A&E clinic here. You are talking about somebody turning up for a booked appointment. I am assuming that the doctor may well know what the circumstances of that particular patient are in any case. Ms Ryan: What would normally happen is that the patient will be told as soon as possible after first contact if they are likely to be chargeable. In an emergency, if somebody has turned up and they are clearly very ill and treatment needs to start straight away, then that treatment will happen, the treatment will start straight away, so there may be a day or two before it is possible to ascertain all the circumstances, to establish that they are chargeable, but you will not have somebody going weeks and weeks into treatment and running up a bill of thousands of pounds and then suddenly being told they have got to pay. That will not happen. Q247 Dr Taylor: No, because as soon as they are told, they will defect, so they will not build up that bill. Miss Johnson: One of the issues is, obviously, that some people do end up receiving charged treatment and are unable to pay, and so trusts do end up sometimes having to write off debts. That is not only in the HIV. We are only concentrating on this, but obviously these regulations cover a much wider area than HIV/AIDS. They cover the whole range of provision. Q248 John Austin: But with HIV, there is a major public health risk as well, which you, as a public health minister, must be concerned a bout. Miss Johnson: Of course, and that is why we want people to come forward for diagnosis, and that is why we are encouraging them to come forward for diagnosis, and that is why diagnosis is free. For many of the people that we are talking about the treatment is also free. The question that you are raising is whether there is a public health advantage to free treatment for those for whom free treatment is not being provided, and what I am saying to you is that it is not like some of the other things for which we provide treatment, where there is a course of treatment and you are cured. Q249 Dr Naysmith: We have evidence, Minister, that you will reduce the viral load by treatment, and that reduces infectivity, and that is known in HIV. Miss Johnson: Yes, "reduces" is the imperative word, I fear, but this is a debate that I am sure the Chief Medical Officer will be very happy to engage in with you. Q250 John Austin: The risk of transmission is very clearly linked to the viral load. The risk of transmission of infection is lower if the viral load is lower. Miss Johnson: My point is that it is not zero. Somebody who has had a course of treatment for gonorrhoea and taken the course has a zero risk. Q251 Chairman: We understand the point you are making. I am not sure everybody would agree with you, looking round the room. What I am interested in is, when we were looking at sex education - and we talked about this in the first part of this morning's session - I have a vivid memory of lots of evidence 18 months ago about the continuing impact of section 28 on teachers' views on what they could and could not say in the classroom, even though section 28 was withdrawn. Are you sure that clinicians understand exactly what they can and cannot do, or could we have an ongoing section 28-type situation, which could have serious public health consequences, because of a lack of clarity about what they can and cannot do, and a fear that what instinctively they want to do could have repercussions? Miss Johnson: I am sure it is possible to produce some examples of confused clinicians with 1.3 million staff in the NHS, of whom quite a lot are doctors. Some of them may not be fully abreast of everything about everything. I cannot say that you are not going to produce some examples like this, but we would be concerned if people generally had some kind of misunderstandings about this, that there were myths of some kind out there. We would, of course, be very concerned about that. That is one reason why the regulations were revised to end up with fundamentally exactly the same basis that they had always had prior to 2004, but they were tightened in a way that made it clearer exactly who was eligible and who was not. I think the main change, which we have talked about at some length, was the 12-month provision. It was never meant to cover those who had stayed illegally for 12 months; it was meant to cover those who were ordinarily resident; it was just that "ordinarily resident" had not been translated into "legally resident," and we just made it clear that that was always the intention of it. So the whole purpose of doing this - and there is a discussion going on currently about primary care in the same way, with consultation - was to consult in a widespread consultation over this. It took a considerable period of time, and Elizabeth may want to say all the organisations that were involved in that. We have done our best to make sure that there is buy-in understanding and that this does clarify the situation considerably. That is not to say you will not find an example out there of somebody who does not understand. Q252 Chairman: As far as Ms Ryan is concerned - and you mentioned earlier on that you do have contact with trust charging officers - you would feel that the Department has taken as many steps as it can do to ensure that the people who are in the front line, the clinicians who will meet the patients, fully understand what these regulations mean, and from a public health perspective, do not feel constrained? Ms Ryan: Yes, I am very confident of that. The guidance is very clear that clinical priority comes first. Q253 Dr Taylor: I am going on exploring that, because what we are missing is an actual clinician on that handle. If I can just pass on a comment that has been passed to me, it has been said by one of our experts that, because of the anonymity and the confidentiality and the open access of these sort of clinics, the doctors do not know every issue at the time when they have to start the treatment, and they are not really able to work it out, and there is no standard way that these people are assessed in clinics in practice, therefore people are being started on the treatment before they are aware at all of the costs, and so there is a huge risk of drop-out. Miss Johnson: There is no reason why those who are managing the clinic should not be having a regular dialogue with the overseas visitors managers. If they are not doing so, obviously, they will necessarily be short of understanding and guidance, but there is no reason why that should not be taking place, and I am sure that the overseas visitors managers stand very ready to have a chat, either with clinics or with individual clinicians, whatever. As you know, people do not just turn up and get immediately put on a script for HIV/AIDS treatment, so it is not just going to happen overnight. Dr Taylor: I can see a recommendation coming! Q254 Dr Naysmith: Minister, this whole area has all sorts of potential ethical dilemmas between doctors and patients, and doctors and their employers, given what we have just been talking about, and doctors having the freedom to start a treatment, and then maybe a PCT deciding that they do not have enough money for it to continue, or whatever reason. We know from evidence that was given to us that doctors do not like this kind of gatekeeper role in this area. Have you had any discussions with the GMC about the implementation of this policy and what it means for the professionals who have to take these decisions? Miss Johnson: Elizabeth may want to comment. It was before my time in the Department that a lot of the discussions were going on, and I am not the Minister who deals with this on a day-to-day basis either. What I would say is that people have had plenty of opportunity to be involved with the consultation. We did discuss the question of easement for clinical decision-making, and that easement was built into the new guidance that was issued. When you say people running out of money, I am not quite sure what you mean. I do not think people run out of money. Q255 Dr Naysmith: I did not say "running out of money". Miss Johnson: I thought you did. Q256 Dr Naysmith: I am sure the transcript will show. There are two primary care trusts in my area. Somebody in my constituency moved from one to the other recently, and they were receiving a treatment paid for by one, and when they moved into the next one, they were told they could not have it, until I intervened. There is room for that kind of misunderstanding in this area, particular since I suspect in some parts of the country all PCTs do not have overseas visitors managers. Miss Johnson: Overseas visitors managers. All the trusts do. Q257 Dr Naysmith: I am sure they do, but in some places they will get a lot to do and in other places they will not get very much to do, and it is that kind of area where you can get problems arising because they just read a circular and think "This is what we do." Miss Johnson: I am sure their association also provides support and guidance as well, and I know that you had the opportunity of taking evidence from Pam Ward. Q258 Dr Naysmith: We are quoting experts, and one of our experts passed me something that I should have known when I was talking about virus load. Basic epidemiology says quite clearly that you do not have to reduce a risk to zero; you only have to reduce it to less than one. Our experts win! Miss Johnson: I note that. I think we shall have to get the experts to do battle. I nonetheless maintain the very firm understanding, which is that there is a zero risk for some things after treatment and there is not a zero risk with HIV/AIDS. Dr Naysmith: I should have known that because of a basic immunology course I did many years ago. That was something I should have known. Chairman: Minister, can I thank you and your colleagues for a very useful session. We are most grateful to you.
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