Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 80-99)



  80. Would you accept that the fact that we frequently fail to address male health as a wider issue has a bearing on the problems that you are addressing here; and do you have any thoughts within your strategy on how we might be much more vigorous about engaging with men? And if it is possible to test on the basis of a urine sample, how we might sort of simplify, rather than kind of having, I can recall, in my youth, hearing all sorts of lurid tales about what happened if you got it, and the kind of tests involved, that actually some of these tests are quite simple, and it may be helpful for people to actually have these in a routine way. Is that an area that you have given any thought to?
  (Ms Hamlyn) It was very well highlighted during the consultation, the issue of men, particularly men and chlamydia, and the need to look at different ways that men can actually access support and services. We want to learn from other places, such as in Scotland, they have been looking at postal systems for testing, and so there are some other examples where we want to explore that further. And, yes, I totally agree that there is a broader issue about men's health. And there is some developing work to really look at some of the broader issues around men's health, and within which sexual health clearly needs to play a part.

Dr Naysmith

  81. We have talked quite a lot about resources already, but I did want to look at HIV, because of the changes that have taken place, that it is now firmly back in the mainstream, after having been specially funded for a while. Is it quite clear that the responsibilities are, in terms of funding, between Primary Care Trusts, Strategic Health Authorities and specialist commissioners, is it clear and transparent who should be funding what? It is HIV I am talking about, because of the way it has been changed, in terms of its treatment, over the last few years?
  (Ms Hamlyn) The key issue now is that PCTs have now received, within their overall allocations, an element that is associated, what previously would have been separate, in terms of ring-fenced allocation for HIV treatment and prevention; so PCTs have the key responsibility, in terms of commissioning. But some of the arrangements, there is a transitional period where there is an arrangement for joint commissioning of treatment, particularly in the context of some of the points that were raised earlier, where you are talking about treatment providers who provide a service to a wide range of areas, it is the importance of those commissioners coming together. So the intention is that there will continue to be some of those collaborative arrangements; so we are in a transitional period, where some of that expertise will develop through Strategic Health Authorities, as now, previously health authorities, playing some part in working with PCTs in that transition, and, clearly, where we are also encouraging the continuation of those joint commissioning arrangements. But PCTs very clearly have the responsibility in terms of looking at their local populations, as I mentioned earlier, their needs, in terms of HIV prevention and sexual health contraceptive services, it is very clearly with them. I think the issues I was talking about were broadly around the way that treatment needs would be commissioned, because of the issue that it is a specialist service.

  82. Really what I am getting at is, there has been some suggestion that some monies have been lost in the sort of transfer in; are you happy to say that it is quite clear now who should be commissioning what, which services, treatment and preventative?
  (Ms Hamlyn) I think it is quite clear, but it is an issue that a lot of concern was raised on this issue during the consultation period, and people were worried about what impact it might have, that it would no longer be ring-fenced, and what impact it might have particularly on the voluntary sector. In our Implementation Action Plan, we have said very firmly that we will be monitoring investment through the performance management mechanisms that we have, through the Service and Financial Framework that we have, to look at investment in HIV.

  83. So what will the monitoring look like, how are you going to do that?
  (Ms Hamlyn) Through this Service and Financial Framework, individual PCTs will be required to say what their investment plans are and what they have spent; we also have the mechanism, through the AIDS Control Act, where they are required to report, and we will be reviewing the AIDS Control Act data requirements, as part of the Action Plan. And we have, in fact, surveyed recently and followed up on a sample to look at plans on investment, and the majority, certainly from that survey that we have done, to date, and we will have fuller information in August, suggests that investment levels have been maintained, the majority, if not increased, in some cases.

  84. Is this, in effect, ring-fenced money then?
  (Ms Hamlyn) It is not ring-fenced any more, no; that was the major change that happened.

  85. So it will depend on your monitoring deciding whether or not the same amount of money is being spent?
  (Ms Hamlyn) The decisions are dependent on the local area; but we will be monitoring the impact, that was what I was referring to, the monitoring mechanisms. Strategic Health Authorities will take up the issues with individual PCTs, and ultimately the Department can step in, if there really is an issue. I was just going to mention the voluntary sector, because that was a particular worry that was raised with us; and, again, we will be, through the voluntary national organisations that we work with, asking for their feedback on where perhaps that is impacting in a negative way, if that is what happens, on particular voluntary sector organisations. So we are setting up a number of different mechanisms to monitor the impact of the decision on mainstreaming.

Sandra Gidley

  86. Can I just clarify something, which I am not quite sure of the situation. Currently, presumably, areas like London and Brighton receive large amounts of money; will that continue in the future? Because there are some parts of the country where the prevalence is extremely low, and other parts of the country where the prevalence of HIV is extremely high, and, very often, those areas need more spent on public awareness campaigns, targeted or otherwise, as well as the treatment; so it seems unfair if everything is going to go into the pot, and those areas with a high incidence do not receive some sort of extra funding. So how will that be monitored?
  (Ms Stanier) The arrangements that were made for mainstreaming meant that, for this year's allocations, an amount of money for each area, dependent on their HIV prevalence, was put into the overall mainstream pot, and it will continue to be the case into the future, that there will be, if you like, a hidden line within the mainstream allocations, so those allocations will continue to reflect HIV prevalence in particular areas.

  87. But the spend will then be monitored to see, how is that audited, in effect?
  (Ms Stanier) As Cathy has explained, we will be monitoring spend. I think, increasingly, looking into the future, we are going to be looking more at how the rates are moving, and comparing that against the particular interventions that local areas are making.

  88. Right; and if patients travel outside their PCT, which can be some distance, because there are areas where there is good treatment, but people may move from an area where there is a low prevalence to an area where there is a high prevalence to obtain specialist treatment, how do the PCTs providing that patient's care get their money back? It sounds as though potentially it could be quite bureaucratic?
  (Ms Stanier) There has been an arrangement in place between health authorities for such recharging to take place; and we are developing the Commissioning Toolkit, that we refer to in the Action Plan, and we are going to be providing further guidance within that Toolkit on how these recharging arrangements need to continue.

  89. So you cannot really say at the moment, is that right; all these toolkits and guidelines are all very well, but it does not exactly help us to gain a clear picture of what is going on?
  (Ms Stanier) It is very complex, and members of our team are currently talking with the profession to make sure that we get the guidance that we do give right; though we do not have a definitive answer.

  90. So the fact that people need to, because people do not want to be in a position where they are denied funding, because this falls down. I think actually it is quite important, if we are providing the service?
  (Ms Stanier) It is very important, and it will be sorted out during the current financial year.

  91. Right; so you have to wait and see?
  (Ms Stanier) I think that is what I have explained, yes.

John Austin

  92. Is there a danger that we have got a sort of deserving and undeserving poor sort of scenario, that the Terrence Higgins Trust has sort of made a comment that there may be a deprioritisation of stigmatised groups, such as gay men, in favour of, say, young people, and that the whole resource allocation may be skewed by local commissioning? Do you think your monitoring is going to be adequate to pick that up, and do you think that the fears of the Terrence Higgins Trust are misplaced?
  (Ms Hamlyn) I think this comes back to the way that we actually look to the requirements through the AIDS Control Act, and we can ask for information down to particular groups. But I think that what I would say is that we have a full commitment, in terms of our national resources, we already put, and Kay can comment further, a significant amount of money through the Terrence Higgins Trust for national programmes, through the CHAPS, the Community HIV Strategy, for national initiatives around sexual health promotion with gay men. So there is a commitment at national level to continue with that. Do you want to comment further on that?
  (Ms Orton) Yes. For a number of years, we commissioned the Terrence Higgins Trust for the CHAPS Initiative and plan to continue; we are currently funding £1.1 million, and that is a national initiative which we want to continue. We also fund the voluntary sector, through something called the Section 64 support scheme, and we fund over £1 million on HIV/AIDS and sexual health.

  93. That is at sort of global and national levels; and, in terms of local commissioning practices, do you think your monitoring processes will be sufficient?
  (Ms Hamlyn) I think it does come back to the other guidance that we give, that Ruth was referring to earlier, that the kind of priority groups, which were set out in the strategy, will continue to be gay men, yes, young people is clearly another one; in fact, we had a huge number of targeted groups that people thought we ought to be addressing. But we will be addressing some of those through the Commissioning Toolkit, through the guidance we give to PCTs, in terms of commissioning practice, but at the end of the day it will be PCTs to look to the local priorities in their area, and I do not think you can get away from that issue, that we are talking about local decision-making here, based on local population needs.

Dr Taylor

  94. I think we have had a lot on resources and manpower. Specifically to Ms Orton, are there are any specific promotion campaigns that you are about to launch?
  (Ms Orton) The main one is the campaign that we mentioned in the strategy, the Information Campaign for Young Adults, and we are currently working with the design agency on developing that, and that has been informed by a review of the research on what sorts of messages and campaigns work best for this target group. So that we are planning to launch that, and, as Cathy mentioned, in the autumn, but the launch may well be phased to take account of pressures that we have already discussed on GUM.

  95. So we can look forward to that sometime in the autumn?
  (Ms Orton) Yes.

  96. Is there an official strategy about HIV testing, who should be tested, when they should be tested, right at the beginning?
  (Dr King) Yes, the strategy has a goal about HIV testing, and this really is one of the issues that came up during the development of the strategy, and that is, in this country, we have, the current prevalence, I think, is 33,500 HIV-infected people; now approximately a third of those are unaware of their infection, and so one of the aims of the strategy is to decrease that undiagnosed pool, so that people can be aware of their infection and receive advice about preventing onward transmission, but importantly receive advice about their own treatment and care. So that is a goal, and in order to achieve that goal we have set a standard that all people coming to a GUM clinic for an STI screen should be offered an HIV test. This was informed by an expert group that was set up, that included GUM physicians, and their observations, and the evidence that some people were leaving GUM clinics with HIV infection and still unaware of their infection, so it was not being picked up because they were not actively being offered an HIV test. And, in order to track how we are doing against this goal, we have set a number of aims, in terms of uptake of the test, and decreasing the numbers of undiagnosed infections, in that group. But we have to bear in mind always that this is an offer of a test, and it is not a mandatory test, and people have the right to refuse that test.

  97. Have you any idea of the sort of uptake?
  (Dr King) The GUM physicians that were helping us in formulating this, they had some evidence from their own clinics, and they felt that 30 per cent uptake at that time was the sort of uptake that they were getting, so we were putting it at 40 and now 60.[5]

Dr Naysmith

  98. This is slightly unrelated to what has been said, but since I have Dr King here I would like to ask the question. I met an asylum-seeker this morning, a lady, who had a pregnancy while in this country, and she was HIV positive, and she had tremendous trouble accessing milk, either tokens or milk substitute, because, of course, she did not want to feed her new-born child. Is there any kind of programme to assist, because she was in emergency accommodation when all this happened, and was unable to access benefits properly; and this obviously happens occasionally, more than occasionally?
  (Dr King) Yes; as you are probably aware, it is the Department's guidance that, in fact, HIV-infected pregnant women, should be advised that one of the interventions, to prevent transmission to their children, is the advice that they do not breast-feed; and in this country, where there is access to formula milk and to clean preparations, that advice stands and it is supported by WHO and UNAIDS advice. There is an issue that we know about, which is the one that you have outlined, and that is asylum-seekers and the cost of formula milk; and we are in discussion with the Home Office, and I believe there is a judicial review at the moment currently looking at the provision of welfare foods, because formula milk would come under that, and the regulations about welfare foods and asylum regulations as well.

  99. It would, of course, be one of the most cost-efficient measures you can do, is to prevent the child from becoming HIV-infected, just by providing some milk substitute?
  (Dr King) Yes. I am aware that there are some local trusts, and also most[6] of our health authorities, that in fact did set up schemes, and one not very far from here, in Lambeth, Southwark and Lewisham, providing the sterilising equipment and the formula milk to their HIV-infected—

5   Note by witness: The aim of the Implementation action plan is to reduce the prevalence of undiagnosed HIV and STIs-in particular, by setting a national standard that all GUM services should offer an HIV test to clinic attendees on their first screening for STIs, and working towards shorter waiting times for urgent appointments in GUM services. Back

6   Note by witness: In retrospect, we are only aware of a limited number of schemes. Back

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