Examination of Witnesses (Questions 200-219)|
WEDNESDAY 10 JULY 2002
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
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.
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withdrawn from services.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services the juniors get withdrawn from would be community service/sexual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
(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
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.
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
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.
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.
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?
215. They are gone.
(Dr Guthrie) They are all over the place. They will
be some place but not necessarily
216. They have moved around but they are doing
the same sort of thing. I am not sure which strategic health authority
you representHullpresumably 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 trueit 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 instanceas 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
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 PCTsand I am
a non-executive member of a PCTand 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
(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