Examination of Witnesses (Questions 60-79)|
WEDNESDAY 26 JUNE 2002
60. Would you be able to supply the Committee
with those sort of two sides of the debate, both what the clinics
are reporting and what is needed, and what they think would happen
as a result of a campaign, and then the Department of Health knowledge,
given the Welsh situation?
(Ms Hamlyn) Yes, we can do that.
61. You said to Richard earlier about, if there
was an increasing need, say, for a consultant, how it would be
up to the PCTs to look at that and employ extra consultants; but
what about training new consultants for the future, what sort
of input are you making into how many we are training for the
(Ms Stanier) We are working closely with our colleagues
who work on workforce projections within the Department. Part
of our Action Plan is a commitment to do a better review of the
workforce implications of the strategy. We have estimated that
there should be an additional 35 consultants who have come through
the training system by 2004, and then a further 25 by 2009. We
are aware that the speciality are estimating that roughly 70 consultants
are currently coming through the training system, but we need
to offset those estimates against how many are likely to retire,
over this time period.
62. It sounds like small numbers, particularly
since a lot of consultants are just working on their own, so if
you just take one, either to retire or go and do something else,
and you have no department, in terms of consultant time; how much
is that a concern to the Department?
(Ms Stanier) It is certainly a concern, and, as I
say, we have committed to reviewing those projections and to working
with the speciality to make sure that the projections are as good
as they can be. But I think, as Cathy said earlier, improving
GUM services is not just about new consultants, yes, we do need
new consultants, but it is also about looking at the overall skill
63. Just going back, I have just been given
some more information here; you said, about the GUM consultants,
thinking we would need £7.5 million for pump-priming the
service, was not that figure actually £14 million?
(Ms Hamlyn) There was £14 million quoted in the
paper; the actual schedule that they showed us, in terms of actually
looking at the impact on reducing waiting times showed £7½
million, and, as I say, they then did a further projection of
another £9 million on the impact of the campaign, and it
is the latter bit which, (which actually is £16 million,
is it not) the latter bit which, as I say, we have a slightly
different view about what really the impact of the campaign will
(Ms Stanier) I think that we are talking about two
separate papers that have been provided by the speciality.
One was looking at a range of pump-priming measures, which totalled
£14 million, and then there was a separate paper looking
at how we could address the immediate capacity issues and the
impact of the campaign.
64. So where is the £6 million you were
(Ms Hamlyn) The £6 million is the money that
we are making available this year proportional to each area. I
have said that the vast majority of that will be for GUM, as I
said, that is available this year; that, given where we are, we
are now in June, and we need some discussions with the speciality
about exactly how we distribute it. That is the money available,
effectively, to improve things for the rest of the year.
65. But the projection is another £9 million
after that, is that right?
(Ms Hamlyn) The speciality were arguing that, over
and above, they suggested that we needed £7½ million
in a full year; what I am suggesting is £5 million will go
a long way to addressing the immediate issues of the waiting time.
66. Six; you just said five?
(Ms Hamlyn) I am estimating that five, sorry, I am
confusing you, I am estimating that probably about £5 million
of the six
will be probably what we will end up doing GUM, but that is, if
you like, a working figure, because we will obviously need to
discuss it further. And I am suggesting that that actually will
go a long way, given that we are only talking about half a year,
towards the kind of projection that the speciality are making
to address the immediate shortfall. Then there is the question
about what impact the campaign will have, and, as I said, the
speciality did do some projections about that, that we can let
you have, and that is probably the easiest way to clarify any
confusion on this, for which, as I say, we have a slightly different
67. Sure; and, in terms of the Welsh campaign
you mentioned, would you accept that the campaign there did increase
the waiting time at clinics from three to six weeks, the waiting
time at clinics?
(Ms Orton) We understand, from our colleagues in the
Welsh Assembly, that the complete data is not yet available, so
it may be that there is some important data that we have not received,
or seen the complete data on that.
68. I want to go on to talk a bit about chlamydia
screening, and the pilots that have been done have shown very
high infection, around 10 per cent; and in your evidence you talk
about, or in the Action Plan, it talks about the national screening
programme will start to be introduced in ten sites, selected from
those areas which have expressed an interest. Given this is a
condition which can be relatively easily treated, and does have
serious consequences, should we not be doing much more on that?
(Ms Hamlyn) I think that there are a number of issues
around this, the pilots were very useful, the two pilots in the
Wirrall and Portsmouth, to really test both, yes, as you referred
to, it showed actually in terms of what the results, of high levels
it was showing. One of the reasons we wanted to have the pilots
was to test the acceptability of the method and the model, and
urine testing was the method and was regarded as acceptable to
women. There are issues that have been raised about, this was
mainly around women, although men were included in the screening;
we are going for an opportunistic screening programme that is
primarily focused on women, but again we want to look at the issues
around men, and men have, again, one of the increasing rates.
In other issues, what we do not know at present, and we have a
study going on, is actually whether there is a need to recall;
if all that happens is a woman gets reinfected again, we do not
know how quickly we should actually then call them back for screening,
so there is a reinfection study going on, and that will therefore
inform our further roll-out. I think probably the third thing
to say is that we really need to build the capacity, and training
needs to be there, to roll out, and we cannot do that in five
minutes, there really needs to be a programme in order to do that
across the country. So it is reasonable, I think, at this stage,
for us to be rolling out just to ten sites and then being reinformed
by practice in those sites, being reinformed by the infection
study, and being able to build the capacity and the training of
people right across the country.
69. So when is there to be a plan for a proper
national screening service, and I say it particularly because
I am aware that if there is a reinfection the population could
become resistant to antibiotics, and then the problem gets more
complicated? Should this not be a thing like the sort of polio
programmes in developing countries, where we say that we, as a
nation, are going to try to get rid of this major problem that
is so easily treatable? When will we be in a position to be able
to have that sort of national screening, to eradicate what is
often a hidden but very difficult condition?
(Ms Hamlyn) We do not have a date for full roll-out,
as yet, and clearly that is something we need to come back to,
in the context of being informed by the ten areas and, indeed,
the reinfection study, but we do not have an end date to launch.
70. Could we just explore that a little bit
more, about the reinfection; why is that so much of a problem
and why have you got a special study looking at it?
(Ms Hamlyn) It is about really thinking about how
quickly someone gets reinfected, and therefore whether we ought
to build in, as you do in other screening programmes, a recall
system, and how that recall system should actually work, bearing
in mind that we are talking about opportunistic screening here.
So I think we do need to look at that, to look at the various
71. Is there a suggestion that people are going
back to partners and getting reinfected, and therefore what you
are talking about is a much bigger problem, in order to do what
Julia wants, to try to eliminate it? As well as treating people
who present with the symptoms, you have then got to go and seek
out all regular partners and then sort that out before there is
any point in doing a big screening programme?
(Dr King) I was just going to make an observation,
that, in fact, we have talked already about Natsal and we have
talked about the difference in sexual behaviour that has occurred
over the last ten years, and those are the sort of two snapshots
that we have got of sexual behaviour, and Cathy has explained
the differences in those; and one of the differences is the increase
in the number of sexual partners. And, clearly, if you are having
unprotected sex with a number of sexual partners and those partners
are changing, you may, in fact, have chlamydia treated and then
be reinfected by another partner.
Dr Naysmith: That is the point I am making,
in suggesting that, in order to have a kind of viable screening
programme, and then treatment programme, it could lead you into
a vast kind of really expensive way of sorting out the situation;
and it might be the right thing to do.
Julia Drown: I would like to add another question
to that, because is there any work done on whether it is actually
more cost-effective not to rely on an opportunistic programme,
on which you would get individuals coming in and turning up for
other things, and offering screening then, but to have one large
national programme, all concentrated around a particular time,
which then gets over much of the stigma and all the other associated
problems with this, but to say, "We are going to have this
national scheme and we want everybody to come forward who has
any slight possibility of being infected, because we want to get
this out of the population; you're doing it not only for yourself
but you're doing it for the wider population"? I would have
thought there was a real possibility that that actually might
be more cost-effective than trying to just pick up people who
are turning up at clinics?
Chairman: But the point is, you could not handle
72. You could not now, but you could build up
to do that?
(Ms Hamlyn) There is an issue about cost-effectiveness
here as well. The original model that was being piloted was based
on work by an expert committee, involving the Chief Medical Officer;
that looked at an economic model of whether this would be an effective
way of doing it, an acceptable way of doing it, but also whether
it was cost-effective to introduce screening in that particular
way. So there is an issue about cost, clearly, in what you are
73. So it has been ruled out, to be less cost-effective?
(Ms Hamlyn) What the model looked at is, the particular
one currently was one that was explored through the expert committee.
I think it would be a matter for you perhaps taking some further
evidence from that committee, if you wanted to explore that further.
74. We would be interested to find out more
about the programme, the reinfection programme?
(Ms Duncan) I was just going to say that the pilots
in the Wirrall and Portsmouth did actually achieve quite significant
levels of population coverage, for example, 50 per cent in Portsmouth
and 38 per cent in the Wirral; so they were successful in terms
of the population they were trying to get at.
75. Could I ask a question about what evidence
you have of STIs being picked up through routine screening or
attendance at, say, contraception clinic, or cervical smears,
or whatever; do you have any sort of figures that indicate the
proportion of STIs that were picked up through some form of health
intervention where a person went to a clinic for something else?
(Ms Hamlyn) I will ask my colleagues whether we have
got any information to hand.
(Ms Stanier) I am not aware that we have any information
(Dr King) We have a surveillance system, from every
GUM clinic in the country, which has contributed.
76. I was thinking more further down the line,
where a person who had not been aware, maybe, that they had got
chlamydia, or whatever, and a cervical smear would pick up that
fact, whether we keep any record of the proportion of STIs that
are picked up through that kind of routine screening?
(Ms Stanier) I am not aware that we do.
77. But it is possible to do that, presumably,
(Dr King) We are looking to improve surveillance of
STIs in GUM clinics, as part of implementation of the Sexual Health
and HIV Strategy, and clearly that national collection system,
which comes from every GUM clinic, it could be one of the factors
that is looked at. But the more complex your data is, in any of
these collection systems, then the more difficult it is for the
clinicians at the GUM clinic and others that are actually providing
it, so it would need to be carefully looked at, what type of question
you were asking.
78. The point I was making would be that, presumably,
it is conceivable for a woman who was attending a family planning
clinic to be examined, and the doctor there to notice that she
had some particular problem, and steps could be taken accordingly
to treat that particular problem. What that brings me on to asking
about is the fact that, certainly as I see it, the screening process
of that nature, where the problems that are picked up are more
likely to involve women than men, therefore what are your thoughts
on how we may engage more with the male population in respect
of picking up and addressing this particular problem?
(Dr King) It is a difficult one, is it not, really.
79. You need to come back to me then. Only I
am conscious that we have, interestingly, an all-female panel
of witnesses; as a male, I feel that I want to ask that question,
because certainly the figures we have got indicate that men have
problems as well, and may well be assisting the reinfection problems?
(Ms Stanier) One thing that we have done already,
as part of the Teenage Pregnancy Strategy, is to issue best practice
guidance about contraceptive services for young men and to try
to make young people contraceptive services more welcoming to
young men, for example, by having specialist young men sessions;
so we have started to look at one part of this area.
3 Note by witness: We will submit both papers
to the Committee with our additional evidence. Back
Note by witness: £1 million is for abortion services. Back