Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 100-119)



  100. So this is something that is on the Department's agenda and is being addressed, is it?
  (Dr King) It is on the agenda, yes, and we are looking to find a way round it, it is quite complex but we are in discussion with the Home Office as well about it.

Mr Burns

  101. I thought if I could just go back to the whole question of awareness, which I know two of my colleagues have raised with you, fairly briefly. If one looks at your memorandum, that we got sent in advance, it was interesting to see in one part of one of your documents, saying that there were substantial decreases in the incidence of STIs throughout the 1980s, but in the last decade there has been a dramatic rise in diagnosis. One also sees, in another of your memoranda, saying, "In 1999 most people questioned in a national study did not know what chlamydia was." It also said that two surveys done by the National Survey of Sexual Attitudes and Lifestyles in 1990 and 2000, show that, in the second one, "there had been an increase in behaviours associated with increased risk of HIV and STI transmission, including increases in numbers of partners," and, "in particular, there were considerably higher rates of new partner acquisition Among those younger than 25 years and this is reflected in the substantially higher incidence of STIs in this age group." As you will be aware, there was, which I think was for the first time ever, a very high profile awareness campaign through television, through cinema, in the mid 1980s, which I think one of you said earlier in this session did have an impact which helped make sure that we were not, as a nation, on the back foot for the next decade or so. We have not had that sort of high profile awareness campaign, I think, to the best of my knowledge, for the last ten years, and yet the evidence you are providing us with suggests that, after, presumably, an impact of that awareness campaign, people got lulled into complacency, a false sense of security, or whatever, and, of course, a new generation has grown up that will be totally unaware of that. Your strategy plan that you made available to us has the national information campaign, and you have said that it will start this autumn, possibly in a staggered way. What I am interested to know is how exactly do you envisage that is going to work? Are you, because of the evidence and the facts and figures of diagnosis, going to have any very high profile campaigns to really bring the message home to everybody, as well as, presumably, specialist awareness campaigns, in targeted, presumably, publications, targeted areas, like GP surgeries, or whatever, or what are you going to do? Is it going to be a big bang approach, or is it going to be a lot of different, more lower profile but more carefully targeted campaigns, or a combination of both?
  (Ms Hamlyn) I think it is a combination of both; and I would probably say a medium bang campaign, really. We are talking about the need for a sustained campaign. Some of the dangers of having a big bang approach is that you have big bang and then you stop; we want a sustained approach over a period of time. We have also learned our lessons from some of those previous campaigns, and, indeed, have done some quite thorough research about the current, and particularly the 18-30 age group, which is really kind of two groups, as you quite rightly say, it is 18 to early 20s, and particularly the issues of changing partners; for later, it is usually the people settling down, and there can equally be some issues in terms of sexual health at that particular point. And it is that group that we are particularly talking about focusing on, but as a mass advertising campaign, but appropriately targeted in media that actually will be seen and appeal to that particular age group, the 18-30 age group. But the age group under 18, we are already targeting through the Teenage Pregnancy Programme, again, in appropriate media; that includes using magazines, looking at radio, potentially cinema, looking at ambient materials, we are talking about an advertising campaign here and being quite imaginative about how we can use public relations more generally, associated with that. The reason I referred to learning some of the lessons is that this particular, the young population we are talking about now, the kind of approach of the kind of fear-based campaigns is not going to work, nor will young people today appreciate being lectured at, I think, from my evidence.

  Mr Burns: Sorry, can I just be clear that I heard you properly. Before you got on to the point about lecturing—

  Chairman: Order. We have a division in the Commons, so we will adjourn for exactly ten minutes.

  The Committee suspended from 5.50 pm to 6 pm for a division in the House

  Chairman: Colleagues, I think we are quorate, so can we resume.

Mr Burns

  102. You were in the middle of answering, before we were so rudely interrupted?
  (Ms Hamlyn) You raised the question about, and I referred to, that we have learned some issues around, and people raise this because they are worried that we might do a replica of the Tombstone campaign; now it had its day, but I think some of the issues about doing a kind of fear-based campaign like that is that, if the threat, and the threat then was presented as an issue both for the gay community and the heterosexual community, if the threat does not bring out the same, to the realities of heterosexuals, as indeed has happened in this country, then people start to distance themselves from the issue. And, clearly, the evidence that we have had from our research from the preamble to our campaign is that people lived through that, and the heterosexual community therefore do not see HIV as a threat, and indeed they do not see it as a risk, but nor do they see it as, are not fully aware of sexually-transmitted infections in general. So our campaign needs to, certainly all the evidence is that fear, for the current generation, that fear-based campaigns are not effective, that what we need to do is a sustained campaign, we need to raise awareness, yes, of HIV and STIs more generally, for the population as a whole, and we need to promote condom use. So I think that is the context of our campaign, particularly, as I say, it will be targeted for the 18-30 population.

  103. What actual evidence have you got that fear does not work, or does not work as well as (persuasion ?) ?
  (Ms Hamlyn) We have evidence from campaigns, actually both here and abroad, I do not know if anybody else could qualify that for me, in terms of research that has looked at what works and what does not work. If it would help the Committee, I can pull out the references for some of that research.

  Chairman: That would be helpful, thank you.

Mr Burns

  104. That would be, yes. Can I ask just one other thing as well. Given that, in certain of these areas, more and more evidence is becoming known, that was not known five years ago, or whatever, how quickly can the Department, as a sponsoring Department for health education, booklets and leaflets, providing straightforward practical information and advice to different target groups, respond to the changing medical-based evidence? I raise this specifically because, I do not know if any of you are aware, but no doubt other officials in your Department will be aware, that the Department of Health has had some ongoing correspondence with a number of Members of Parliament involving an issue that one individual brought to these MPs' attention, which was to do with HIV and oral sex. And it seemed to me, to be fair to the relevant Minister, who was Yvette Cooper, at the time, that what the Department said they were doing on the increased knowledge of the problems, or the potential problems, they were responding in what I certainly considered to be a reasonable way, though there was a criticism from the person particularly concerned that the timescale was not quick enough. And you have now, and I think it is the Terrence Higgins Trust with their booklets, changed the phraseology in that section, but it took some time, and the Government argument was, you know, "We have got X tens of thousands of these booklets, and it's a relatively minor part of the whole area, and when they run out they will be redone, replaced and updated." Is that a reasonable situation to be in, because scientific evidence is changing the whole time, and you cannot just pulp a whole section of booklets and advice given out every time there is a change, unless there is something really dramatic; and what you did was a perfectly reasonable way to approach it, and that is the way you will continue to approach this area, with increased medical knowledge?
  (Ms Hamlyn) I think there are a number of points I want to make. More generally, in our Action Plan, we have referred to a review of leaflets in general, and I have already commissioned that piece of work; that is looking at the availability and how leaflets get used by people, users of services; and, indeed, it is leaflets not just produced by, or funded by, the Department, but through the professional bodies. And there are issues about, all sorts of issues, in relation, that have started to come out about that, about how people access that information, how it is used within a medical context, and, indeed, where they need updating, whether people, professionals, at a local level, are aware whether they are using the most up-to-date piece of guidance. And we do need to look at issues such as simple things that can be put down, to put dates on documents, that we can have mechanisms to withdraw, systematically, documents, where we need to, where we need this change, and where we can make aware to professionals in the field about a new document. Those are some of the measures that we are looking at, more generally, on leaflets, to do, whether they are ones that we produce directly or whether they are ones that are funded through another organisation.

Siobhain McDonagh

  105. I want to look at the area of contraception and terminations. How will you address the staffing shortages in community contraceptive services; and in the document you make much play of having different sorts of facilities, both at GPs' and contraceptive clinics themselves? But, in my own experience, from my own area, which is a part of south-west London, those community contraceptive clinics are closing, rather than opening, and now almost exclusively, particularly in the less well-off parts of my borough, which is the London Borough of Merton, GPs really are the only people who are providing a contraceptive service?
  (Ms Hamlyn) Yes, I have heard a number of examples of that, and certainly through my visits across the country people talk to me about the issues of difficulties of recruiting staff into the profession, and being able to retain staff; so there are a number of issues that we need to pick up, as part of our overall Workforce Strategy. On the issues particularly of staffing levels in community contraceptive clinics, there is likely to be, if you look at the numbers in consultant posts, again look at senior clinical medical officers and the numbers going to retire, there are issues whether we are going to keep up with the numbers that we need to have, in terms of consultant posts and associated specialist posts. And the Royal College, the Faculty is pursuing that issue, looking at additional training programmes, looking at how that can be addressed. Also, this year, we have funded the Royal College of Nursing to develop a distance learning pack for nurses, and, of course, not everything in community clinics is done by doctors, and again there are the skill mix issues. Now having a distance learning pack will help, but clearly it is not going to solve the whole problem. And I think it comes back to the wider training strategy that we intend to develop, which is intended to look at all professional groups, it is intended to look at what is available, in terms of training, intending to look at the issue within the workforce study, the issue of training posts, and the issue of different types of staff that can be used for different purposes. There are very good examples across the country where you do not need doctors to run a contraceptive service, you can have nurse-led services, we have the role of pharmacists now providing provision of emergency contraception, and you have examples of services, indeed, where youth workers, social workers can have a role in providing advice, and, indeed, the distribution of condoms. So I think there is a range of different issues that can start to address, quite rightly, the problems that you are mentioning.

  106. And how will you address the current iniquity of access for termination of pregnancy services; here, it has got particularly for rural populations, but I have a case with me of a GP who has recently written to me, again, in south-west London, concerned that his patient had to wait in excess of five weeks for a termination at a major London hospital?
  (Ms Hamlyn) Through the strategy referred to, the issue of actually trying to address the issue of access to abortion, and indeed we are setting a standard that PCTs need to ensure that women who meet the legal requirements for abortion have access to abortion within three weeks of their first appointment. That is a standard that we expect PCTs to start measuring against, and, indeed, our intention would be that by 2005 that standard is fully adhered to.

  107. May I just ask you a question about that target. Surely, the answer then will be to delay longer before you get your initial appointment; if it is only three weeks after you have seen the consultant?
  (Ms Hamlyn) It is the first referring doctor, we are talking about.

  108. So the GP?
  (Ms Hamlyn) It is three weeks from the first referring doctor is the issue. Now we do know that there are issues; this standard is intended to address some of the issues of waiting that you are talking about, and, indeed, some of the issues where local commissioning policies can be quite restrictive, and we do know examples, like you quoted yourselves, we know a particular, difficult issue for the younger age group, young teenagers tend to present late and then it becomes a real, big issue, and particularly if they have got to travel distances. So I think we are very serious about addressing this as a particular standard, it is in our Action Plan. Through the Commissioning Toolkit, we will be incorporating good practice, in respect of abortion services, again to provide easy access and to be obviously the standard that we are setting.

Julia Drown

  109. Just carrying on from that, even three weeks is quite a long time to wait?
  (Ms Hamlyn) It is a maximum. Clearly, one of the debates that people have had is that, for some women, they need the opportunity of thinking about whether it is the right decision for them. I think it is a balance between not rushing women straight in, but actually having a reasonable time. It is in accordance with the Royal College of Obstetrics and Gynaecology, so it is a guideline that is consistent with the Royal College.

  110. But, for those who have firmly decided, would your aim be something much better than that?
  (Ms Hamlyn) I would hope that they have a very smooth, easy access actually into services, yes, when they want a service.

  111. The other thing I wanted to ask about was encouraging better methods of termination, safer methods that do not involve general anaesthetic; what are you doing to encourage that, and will you be funding any such facilities being developed, particularly in Primary Care facilities?
  (Ms Hamlyn) In our Action Plan, we have referred to our pilots, of looking at termination of pregnancy in non-traditional settings, but within the law, and also looking at improving early termination, which avoids the issue of medical complications, in terms of later termination. So those are pilots that we would be taking forward, as part of the Action Plan.

  112. And we have got those details in the Action Plan?
  (Ms Hamlyn) It is in the Action Plan.

John Austin

  113. I want to come on to toolkits and piloting in a moment, but can I just go back to this issue of mainstreaming versus ring-fencing, and ask, what is the future of the AIDS support grant that is made to social services departments for the care of people with HIV and AIDS?
  (Ms Stanier) We are currently reviewing that grant. We do feel, in particular, that there is a need to simplify its administration, because at present we ask local authorities for estimates and then we allocate funding on the basis of those estimates, and then we do a second process in year. But there is certainly scope for simplifying those procedures.

  114. But is there a risk that it may get lost in the just general grant allocation, resource allocation, to local authorities, or will it still be specific?
  (Ms Stanier) It is the case, as you are aware, that there is a general move towards more mainstream provision of funding, both for the NHS and local government; so that certainly is a possibility, but the review will be concluding later this year.

  115. But there will be systematic and careful monitoring of what happens in local authorities, if you change the system?
  (Ms Stanier) We would approach it in exactly the same way as we have for HIV mainstreaming, to make sure that proper management arrangements are in place.

  116. But you have referred elsewhere, evidence has referred elsewhere, to somewhat cumbersome data exchanges between the Department of Health and health authorities; what steps have you got to improve that, and what is the role of the Health Development Agency?
  (Ms Stanier) If you are referring, in particular, to the AIDS Control Act returns, it is equally the case that we are in the process of reviewing those returns, with a view again to make sure that we are only asking for information that we really need, and that we make good use of that information, for example, by collating it at a national level and actually publishing the findings. The Health Development Agency do not have a particular role in that process.

  117. So what is their role?
  (Ms Hamlyn) The Health Development Agency, we have, in fact, commissioned them to pull together the best possible evidence of what works, in respect of HIV and STI prevention, and that is very much in terms of their role about drawing together evidence, not new research but reviews, and that evidence will be made available to the field.

  118. Can I come on to the issue of the implementation of the strategy and the toolkits, which you mentioned, which, clearly, you see as critically important for the success of the strategy. To what extent have the providers and patients been involved in their development, and how will they be piloted to ensure that they are valid?
  (Ms Hamlyn) In both cases, in terms of the Health Promotion and Commissioning Toolkits, our date of completion, is set out in the document, so we are not talking about until late summer or autumn to publish those, so it is not the case that we have a document now. During the consultation period, the idea of having a Commissioning Toolkit received overwhelming support, and the process by which that is being developed will involve a number of people from the field, who are already involved, in terms of professionals in the field. As I have also referred to, in the Action Plan, it is the intention to set up ongoing methods for user involvement, at a national level, and there are currently arrangements by which we use various mechanisms for involving through key national voluntary organisations, in terms of user involvement, currently, but we need to substantiate that. And those are the kinds of mechanisms that we will want to use, in the development of both these Toolkits, and indeed any further guidance that we want to produce.

Dr Taylor

  119. We have talked a bit about PCTs, and the tremendous responsibilities being devolved to them, and I am terribly worried about them, particularly those that have only just started this year, and whether they are going to have the capability of really doing everything. Now do you have plans actually in place to ensure that PCTs are equipped? In your Implementation Plan, they have to identify a sexual health and HIV lead, with appropriate level of seniority and public health expertise. Are there enough of these people around, and, generally, what support are you going to give the PCTs with this crucial role that they have not actually had before?
  (Ms Hamlyn) In every PCT there is now being appointed, and the vast majority have been appointed to date, a director of public health, and within every PCT there will be health promotion, people with a health promotion background, previously who had worked for health authorities, and there may be arrangements whereby one takes a lead on behalf of PCTs. So there are the people there. We have asked for every PCT to identify a lead, we have not got a full list of those at the moment, but we intend, obviously, to get a full list of those, and the intention will be to really create that into a network, a network where we can ensure that they get all the up-to-date guidance and information, that we can build in through seminar programmes to develop their own skills. We are looking at what kind of support can be made available at a regional level, through the regional public health groups. The Commissioning Toolkit that I referred to earlier, our intention is to have seminar programmes, to invite these leads to, in the autumn, once that is available, and there will be similar programmes, seminar programmes, for the Health Promotion Toolkit. So we are building in training and development as part of really developing that capacity, which we feel is key for the success of the strategy.

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