Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 200-219)



Jim Dowd

  200. Can I just pick up on the point about numbers not coming through from the specialism. You say it is a numbers game, I am not quite sure what you mean by that?
  (Dr Guthrie) There are national training numbers. Obstetrics and gynaecology has got so many training numbers, and that is the number of juniors which come in at the bottom and work through five years to come out with that certificate at the end of five years which is a specialist certificate. The College has got so many numbers. The trainees come through as general obstetricians and gynaecologists and some of them become sub-specialty trained and provide five sub-specialties, one of which is sexual and reproductive health. The numbers are competitive. There are training centres, you have to be specially accredited as a training centre. There are only so many trainees to go around and the trainees choose what specialty they want to go in to. The total number of trainees in obstetrics and gynaecology has been cut over the past few years. This year in the whole of the Yorkshire region one trainee came in at the bottom end. This is all part of national manpower planning.

  201. It is not that they are choosing to specialise in other things?
  (Dr Randall) No.
  (Dr Guthrie) There are more people wanting to do obstetrics and gynaecology than there are posts for them, without a doubt.

Julia Drown

  202. Is not obstetrics and gynaecology the one specialty we have a surplus of people in?
  (Dr Randall) We did have.
  (Dr Guthrie) It has swung the other way. The other unfortunate thing with obstetrics and gynaecology is that at the end of the day junior doctors' hours have been cut, junior doctors' numbers have been cut, workforce planning has got turned on its head and now we have a shortage of doctors coming through; we have to protect very intensive care areas like the labour ward. So when doctors are around for half the number of hours they were, that is not a bad thing, but when they are around less they get withdrawn from services. Surprise, surprise, one of the first services the juniors get withdrawn from would be community service/sexual health services. They do not get the experience. When they come to make career moves, sexual/health services is not in there and being thought of as a career so we are getting doubly cut.

  203. In terms of the Royal College, presumably the Royal College is proposing now to have more obstetricians and gynaecologists and part of her role would be to do family planning work, although the whole process of family planning and STD`S will be merged, so some new consultants will be coming through to take this huge workload on.
  (Ms Thomas) Kate is better placed to talk about that than me.
  (Dr Guthrie) Certainly the post graduate dean are extremely aware of this particular shortfall in specialists in this area. I know it has been addressed between the Royal College and the Faculty of Family Planning and the post graduate deans for obstetricians and gynaecologists, so we are aware of it. I think when we say total number of trainees that is very political, is it not? O & G is given a number of trainees. It cannot choose how many trainees. Currently, it is requesting more.
  (Ms Weyman) On this issue of nurses, we have not mentioned nurses and nurse training—

  Mr Burns: Hang on, we are about to come on to that.

Julia Drown

  204. In the areas of abortion and contraception as well as sexual health there is a much wider variety of professionals who could take on aspects of patient care. Can you inform us about training requirements for this to happen and in what other areas you feel professions could be doing more?
  (Ms Weyman) Nurses do play a significant role already in the provision of contraceptive services. At the moment because as there is not an accredited body for nurse training in England at the moment, there is an issue about what happens to those courses which are accredited currently when they come to the end of their accreditation, whether the nurses will then have transferrable qualifications to other places and whether the content of the courses is standardised. There is a major concern about what is happening with the provision of accredited course for nurses at the present time and with the volume of places on courses for nurses to get on to. There are often long waiting times for nurses to get trained.

  205. Should pharmacists be doing more?
  (Ms Weyman) The issue there needs particularly to relate to the provision of hormonal methods, as to what extent pharmacists can be involved in that. Certainly I would have thought with some aspects of repeat prescribing there is no reason why pharmacists should not have a greater role. The other issue in terms of staffing is the clinical staff, which is being addressed from what you are saying. There is a major problem there.

  Julia Drown: We have had a number of submissions, as you can imagine, describing crisis and huge pressure on services. What about in the other staff groups?—are there issues that need to be addressed?
  (Dr Guthrie) When nurses go off for training you need backfilling. If the nurse goes off to training who is doing the work the nurse is doing? There is an issue there. There is a bit of non-joinedupness between looking at the new prescribing rules; nurse prescribing, nurse repeat prescribing, patient directions, which is very much looking at midwives and practice nurses and forgetting that sexual health desperately needs to get nurses into this sort of role. As Anne said, they are extremely capable in delivering the service and they can deliver so much more. As the sexual health service moves forward it is ridiculous having doctors doing things that somebody else can do. Doctors should be doing what only we can do. As well as putting in the nurses what we have learned from genito-urinary medicine services is that there is a huge resource which is, as yet, untapped in the voluntary sector. A very good example there is dealing with young men. The best way of communicating with young men is using young men and training the voluntary sector to deliver what you do not need medical or para-medical personnel to do. It is about being inventive about how you deliver the services, spreading the load.

Dr Taylor

  206. In my own area three PCTs have clubbed together and given sexual health to one of the three PCTs. Is this general? How is it going to work? Have you confidence it is going to work or are you very worried?
  (Dr Randall) I think we are worried. That seems to be a general pattern that one PCT is looking after it on behalf of three or four others. The added problem is that GUM is still stuck in the hospital with the acute unit. If we are now going to be talking about having a sexual health lead and perhaps some money that is coming in for sexual health, how is this going to be apportioned? Is some going to go to the hospitals for GUM and some going to go to PCTs for community clinics? Are community clinics going to be competing against GPs for what they want in their own practice? I have got more questions than I have got answers.

  207. What sort of questions should we be putting forward in our report, what sort of advice for PCTs?
  (Dr Randall) We are told that we are going to have a commissioning tool kit as part of the Strategy which unfortunately, none of us have yet been able to see so we do not quite know what it is going to include. It is fair division of the cake, if you like, and openness in how you balance the various demands from GUM, HIV and STI, to contraception, to abortion.

  208. Do you not think "commissioning tool kit" is a bit of jargon?
  (Dr Randall) I would not like to say.

  209. What will be in that tool kit or what would you like to see?
  (Dr Guthrie) If we could be confident that we stuck to the principle of the Strategy which is having the appropriate service delivery for the needs of that population. If that is our starting point and that is what is followed through, why should any of us feel threatened or pressured? We should not be competitive about it. This is about what a local community needs. If the local community appraisal is done with public health and whoever together then there is no threat to anybody. The anxiety is, I suppose, that we really have no idea and the PCTs, to be fair to them, have no idea. Unluckily they are still very immature and I think if the PCTs had the answer they would tell us, but they themselves are trying to get to what is going on.

  210. What sort of distribution is there of people like yourselves, people who can advise us?
  (Dr Guthrie) There are not that many of us really.
  (Dr Randall) I do not know about Kate, but I do not sit on my PCT board so any clout with them is remote.
  (Dr Guthrie) For me neither.

  211. So a very strong point we need to make is that PCTs need specialist advice on these particular services?
  (Mr Jones) I would support that entirely. From our role in the independent sector sat at this end of the table we currently have commissioned arrangements with about 80 commissioners, many of which should I say are aligned in way that you have suggested. A number of them have joined together to commission a service because with those services that involve relatively small numbers it makes sense to commission on a more corporate basis. Certainly in our experience these commissioning bodies gain experience. Some of them have only been in place for seven months and there has been an enormous change round of staff within them, but they ought to be encouraged certainly to approach the local community experts and those bodies that offer a service into that community.[15]

Julia Drown

  212. Earlier, Dr Guthrie, you said about how you need the power to be able to direct on the ground, it does not need to come from the Department of Health but you need the power as leaders in the field. What powers do you need?
  (Dr Guthrie) The power to sit at a table with commissioners.

  213. This is the PCT?
  (Dr Guthrie) Or the strategic health authority. I would probably put it in that area for those who provide care. Those who are paid to be experts in our field to sit with commissioners, to have the power to get the information we require, to then design appropriate health services, and also to have flexibility within that. The funding round starts very soon. The funding scrap will now go on until next April and then it will start all over again. It is not a very flexible system at all.

Dr Naysmith

  214. How is it different now from what it was before the PCTs were set up? Presumably there is a relatively small local health authority that did what this combined PCT group is doing? What is the real big difference?
  (Dr Guthrie) We are trying to deal with people who do not know what they are doing. I am speaking to four people instead of one.

  Dr Naysmith: What happened to the people who were commissioning the services in the area health authority?

Mr Burns

  215. They are gone.
  (Dr Guthrie) They are all over the place. They will be some place but not necessarily—

Dr Naysmith

  216. They have moved around but they are doing the same sort of thing. I am not sure which strategic health authority you represent—Hull—presumably you have got somebody in Hull who was commissioning these sorts of services—
  (Dr Guthrie) Not yet I have not.

  217. Or related services somewhere else?
  (Mr Jones) In many areas that is true—it is the same people and they are moving around. When you ask the question what is it we need to try to ensure, we need to encourage them to stick to the Sexual Health Strategy and to give them the authority to do that because they have conducted a baseline assessment to try to identify what is available in each area and therefore how they need to move from here to there to meet the terms of the Strategy. If all commissioners and public health managers can be given the authority to stick with that and not get frightened off by media headlines, for instance—as we have experienced over the last two or three days over a perfectly sensible suggestion by the Department of Health to make one particular service a bit more accessible.

  218. The strategic health authority level is probably too large for you to get at what you are trying to do, which is smaller, more community-based but bigger than one PCT.
  (Ms Weyman) The reality for the PCTs—and I am a non-executive member of a PCT—and what I am seeing very much is that these issues are not high priority issues. Teenage pregnancy is on the list but the rest of it is not and there is the question of what is meant by sexual health. When somebody says they are commissioning for sexual health across several PCTs, are they commissioning for all these services we are talking about or are they commissioning for only some of them? How do we see these relationships between those PCTs that are providing directly for themselves and those for whom they are buying it. I do not think we should be too sceptical yet about the commissioning tool kit until we have actually seen it. I think it will be evolving. I do not think it is going to be a product in four months that is going to answer all the questions. We do not have the evidence to answer quite a lot of the questions. I do think there are a lot of issues such as the fact this is not a national service framework and it does not have that priority. In some PCTs there will be people who are totally committed, who have got broad vision and who really can use the Strategy to go forward; in a lot of other places that is much less likely to be the case.

  219. To be fair, that was probably the case before.
  (Ms Weyman) It was the case before but I think having a Strategy we would hope that we are going to see something better.

15   Note by witness: BPAS provided 29,202 treatments in 2001 to women on contract with the NHS with 62 commissioners to a value of £9 million. Back

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