Examination of Witnesses (Questions 180-199)|
WEDNESDAY 10 JULY 2002
180. Why is it right to go that way rather than
go a different way and say "do less"? They would argue
strongly they have got it right, a culture of no sex before marriage.
(Dr Guthrie) Certainly in countries which have an
environment ofmaybe a new wordreligiosity, is the
word they use, there is a different attitude towards sex, whether
it is Catholic or whether it is Protestant, whatever faith it
is, if it is a very religious country they do have a bit less
of a problem because that is the culture of that country. The
UK does not have that culture either.
(Ms Weyman) The UK culture is a very confused culture.
(Ms Weyman) On the one hand you have this "We
cannot talk to children about sex, we might approach on their
innocence" which I think is a very strange concept because
why is sex somehow associated with guilt. We have that aspect.
Then you have all this terribly overt sexual imagery, sex selling
products, the total preoccupation in a lot of the media with the
sex lives of people who are well known. It is a really confused
environment in which young people, and the rest of the population,
are engaging in their sexual relationships and seeking advice
to prevent pregnancy and to prevent infection. I was interested
in your comment about whether the things I was saying go far beyond
where the British culture is now. I think the difficulty is how
we judge where the British culture is at and where people are
at. If you believe what you read in the newspapers, particularly
some of them, you get a very different view from what people actually
think. I think the example here that I would use is around attitudes
to abortion because when you do the opinion studies you get, Ian
quoted 60 per cent, some studies have shown higher percentages
of people who are very accepting of abortion but if you read the
popular press you would think that was not the case at all. You
cannot judge it on the shock, horror, hysteria that we read in
the press. Most people are a lot more sensible than that and a
lot of parents would like to be able to talk to their children
and would like their children to know but they do not know how
to do it because they have no role model themselves because their
parents did not talk to them.
182. Does Ian want to respond?
(Mr Jones) Could I make one point. I agree entirely
about the concerns we should have about sex education and providing
better information but with the best will in the world if we introduce
a 100 per cent effective sex education programme from tomorrow
we have still got some ground to make up here and it is going
to be some time. As a health management person here, I am concerned
that we do not lose this opportunity in the Sexual Health Strategy
to improve the delivery of services which we need now as opposed
to saying "Let us get the education right first", we
need to get the services right so the education can follow through
Sandra Gidley: What has been very striking throughout
this inquiry so far is the first panel was all female, I think
uniquely so. We have a token man here today.
Julia Drown: Most welcome.
183. Yes, most welcome. We had predominately
females we spoke to when we had our visit to Brussels. When you
are accessing services I think there is very much the feeling
that this is girls stuff and there is a lot of pressure, I think,
put on the female to sort out her contraception and all the rest
of it. Where do young men fit into this? It seems to me they should
be taking more responsibility rather than less. Family planning
clinics seem to be geared towards the female, is there something
which needs to be done here or are there young men's clinics out
there which are not available?
(Dr Guthrie) Historically you are absolutely right,
it seems to be the British thing that it is the woman's responsibility.
When you do have a young man coming along with his partner to
the clinic, whether it be a hospital clinic or a community clinic
and you say "Bring your partner in" she says "No,
no, leave him out there" and he says "No, I am not coming
in, that is another British thing. When I have been to Europe,
and I have been to Holland to see how they do things over there,
they are just amazed at our approach". They say "Are
you surprised you have got problems because you are only talking
to half your population?" There is a culture here of men
not having to take responsibility. The Dutch deal with couples.
Of course if you deal with a couple, if it is the woman who has
got a problem with her contraception or has an unintended pregnancy
(a) 50 per cent of it is something to do with the man and (b)
he may learn something so he goes into another relationship and
takes some knowledge with him. It is something we do very badly
here, we know we do very badly so we are trying to be more inclusive
of men and have services which are appropriate and attractive
184. Are there any examples anywhere around
which may be interesting for us?
(Dr Randall) There has been a lot of outreach work
with young people with clinics sited in non-health centre premises.
They might be youth clubs or whatever and they often have youth
workers there as well who have gone and worked with the young
people and they say, "Come along on Tuesday, you will see
me." That is attracting quite a lot of young men but an awful
lot of our abortions are older people over 20 and it is a question
of how we get those men in. I think that is incredibly difficult.
Again, it is all to do with stigma. It is okay for them to brazenly
walk in but they are not accountable.
185. Something that occurs to me just as a supplementary
to throw into the potyou can get your oral contraceptives
free on prescription, you cannot get condoms free on prescription;
should that be changed?
(Ms Weyman) We would like to see free condoms. One
of the issues about the involvement of men again comes back to
greater integration of services across sexually transmitted infection
services and contraception because men do go to GUM services.
Four or five years ago we did a project working with professionals
in GUM to get them to raise contraception issues with the men
they were seeing. If you have got a much more joined-up service,
particularly if they are being provided from the same location,
it becomes much easier to at least meet men and talk to men who
are coming into a sexual health service about contraception. I
know that we do not want to talk only about education but that
has also been the case in sex education. It has very much in the
past been provided by women and focused on girls, and boys were
seen as the problem. That completely alienates them and now there
is beginning to be a change towards taking the needs of young
men on board and giving them the sex education they need as well.
I think that we need to try and look more imaginatively. When
a woman comes to see her GP, the GP may very well ask her about
contraception or might ask her about these issues if he believes
she is likely to be sexually active. He probably would not ask
a man in the same way and yet why not? These are about professional
education and prejudices and stereotypes and what you say to whom
or what questions you ask people.
Mr Burns: We will move on rather than give a
disproportionate amount of time to this area. Dr Naysmith?
186. I am sorry, Chair, it is something we have
touched on already, which is inequalities and anomalies in the
services geographically and also sociologically as well. The Strategy
states that the accessibility of contraceptive methods that are
available varies very widely. What do you think the reasons are
for this? We touched on this a little earlier so if you could
talk maybe not so much about the main reasons but what we can
do about it.
(Ms Weyman) We talked about the reason to do with
funding and training doctors and what they can provide. There
is an issue about knowing the facts because the data collection
we have is not the same across what happens in clinics and what
happens in general practice and we have very little information
about what is actually happening in general practice, what methods
are being provided, and really if we are going to look at inequalities
and look at whether the Strategy works, we need to have a much
more consistent collection of data across the different groups.
187. I imagine there is very little cross-referencing.
The National Health Service is notably bad even in terms of data
transfer from GPs to acute hospitals. I imagine this area is even
(Ms Weyman) It is not necessarily a question of sharing
of the data; it is a question of collecting data in general practice
and returning it. Family planning clinics make returns about who
they are seeing and what they are providing. GPs are not doing
that. GPs get a fee for providing contraceptive advice. At one
time you used to be able to get information about how many women
were being seen in general practice. You cannot get that information
188. Why does that not happen any more?
(Dr Guthrie) In some areas nobody cares.
189. How can you make them care if you think
it might be valuable?
(Dr Guthrie) You have to make them care. The Strategy
has to get into monitoring and evaluation. That has to be, I am
afraid, top down. If you look at the way it is laid down
190. So more direction from the centre, more
red tape? The things doctors particularly are complaining about?
(Dr Guthrie) No, service leaders like Sarah and I
are very motivated to provide a good service in our areas. It
is about working with the commissioners of the service to know
what are your areas of need and to provide the services. It needs
to be given the power to do that.
191. Does anybody else want to come in?
(Dr Randall) There are still a lot of services out
there which have no lead at all. We have 171 community services
but a quarter of those have no medical lead whatsoever so those
services are probably led by a nurse or manager, so where are
you going to get your direction from in those services? You do
not have a lead so your business about standards and helping has
to come from somewhere. We would hope it does not have to come
from as high up as central government. If it is going to come
from people who are going to lead the service and help GPs there
has got to be a local leader there, and some areas do not have
that. That is back to funding, training and back to the same old
192. What about the three levels of service
that are mentioned in the Strategy?
(Dr Randall) There will be some areas which will find
it very difficult to run level three because they have not got
the consultant or senior lead doctor there to do to it, so those
GPs could find it quite difficult.
193. What does that mean for staff? Does it
mean increased staffing, improved staffing, more training?
(Dr Randall) It all goes back to how we get consultants,
which is a training issue because family planning and contraception
is not seen as a specialty whereas GUM is, so training people
to become consultants in family planning is actually very difficult.
You have to go by the obs and gynae route whereas for GUM you
go up a different route. Consequently it means that at the moment
we are very short of consultants and there is no easy way of achieving
the numbers that we need.
194. What about the putting together of GUM
and contraception? They have evolved quite separately but the
Strategy suggests bringing them together and integration. Is that
a good or bad thing?
(Dr Guthrie) It is very welcome. It has been a ridiculous
Dr Naysmith: I would have thought some of you
would have thought it was a bad thing.
Jim Dowd: You were wrong.
Dr Naysmith: I was wrong.
195. The new GP contract suggests that family
planning will be included as additional services. How will this
impact on current service provision and appropriate delivery of
contraceptive services across the NHS?
(Dr Randall) We do not know is the answer to that
because we are not sure what is going to happen to the pot of
money that went out to the GPs for their item of service payment.
Is that pot of money still going to be there for contraception
or is it just going to disappear? There may be some GP practices
who will say, "Yes, we will continue to provide contraceptive
services"; others might say, "If the money is not there
we are not going to provide it." At the moment they get quite
a lot of money, they get about £60 for fitting IUDs. For
some that might be quite an incentive to carry on doing so. If
that is removed where are women going to go to get their IUDs
or coils fitted? Again, that could possibly put pressure on local
community services. We do not know until we know how the new contract
is going to pan out.
(Ms Weyman) I agree with what Sarah says. We want
to be sure that that pot of money is not lost because it is something
that is being spent on contraception at the moment. In the GP
contract, from what I have read about it, there will be standards
attached to those additional services in return for payment, although
the amounts of payment have yet to be determined. It seems to
me it is really important that there is a link between the Sexual
Health Strategy and the people at the Department of Health responsible
for the Sexual Health Strategy and whoever is negotiating those
packages and how they are going to be implemented. It tends to
be that the GP contract is negotiated over here and the Strategy
over there, and it is just not going to happen if that is the
case. One of the things that we have always been really concerned
about is that the fee is paid regardless of what is provided and
regardless of whether the doctor is trained to provide anything.
The doctor can get a fee by just asking a woman whether her contraceptive
needs were taken account of at the moment. The new contract could
be a real opportunity to ensure that there are good standards
in general practice and there is also the issue of the PCT having
an overview of what is going on and making sure there is sufficient
provision so that if the GP practices in their area are not providing
the service, they are making sure that the investment is going
in to providing it through other means. It could be that these
changes could be a real opportunity for improving the quality
and delivering the standards as set out in the Strategy or it
could mean that we get less than we had before. I think what is
important is that it is put in place, and we make sure it is the
former and not the latter.
Dr Taylor: Can we move on to the place of PCTs.
Mr Burns: Hang on. I think we will let Siobhain
carry on with her questions first.
196. Can you give your views on the training
requirements for specialists working in the field of contraception
and for basic training in primary care and community clinics?
In particular, do you feel that improvements need to be to GP
training to ensure the consistency and quality of GP contraceptive
(Dr Randall) Can we talk about GP training first.
At the moment, the GPs would say that what their trainees learn
in their three years' vocational training is sufficient to provide
them with all the knowledge that they need for contraception.
There has been a lot of debate with the Faculty of Family Planning
who organise specialist training, if you like, about whether or
not GPs need to take the Faculty's Diploma. I think that is a
debate that you can have. As long as GPs receive adequate training
to provide level one service then I think that could be acceptable.
The problem arises when GPs want to offer other services, then
you need to be looking at specialist training in how to fit an
IUD. I am sure we would all want to think that our GP has been
taught how to fit a coil before they go ahead and do so. There
is no need for that to happen at the moment. Women are not going
to go to their GP and say "Excuse me, how many coils have
you fitted in this last year" before they decide whether
or not they are going to let that person do so. I think we need
to get the Faculty of Family Planning and the General Practice
Colleges together and sort out some basic training. I think at
level two we are looking probably at the Faculty to continue perhaps
its specific training for things like implants and coils. Then,
again, it goes back to Anne's topic about tying in, if you like,
standards here, whoever provides these services is trained to
do so. I think that is where I would come from.
(Dr Guthrie) Higher levels of training. There are
two issues. One is you have to have an adequate number of doctors
trained to deliver the service. Right now if you look at workforce
planning, the Royal College of Obstetricians and Gynaecologists,
where ultimately most of the consultants come from in this field,
there are a very small number of specialists coming through. That
is a big issue. There is a reduction in total numbers of trainees
and of the numbers of trainees available, a very small portion
are specialising or sub-specialising in sexual reproductive health.
The second thing is a lot of the services are delivered not by
consultants but by what are called career grade doctors. The Faculty
of Family Planning does have a training programme for career grade
doctors, it is a modular training programme over three years.
We have looked very carefully at training, not just training but
also maintaining standards so not only do you want to know that
your doctor has been trained to fit your coil but he is keeping
his skills up to date. We do have standards for training at general
practice level, career grade doctor level and consultant level.
The training is there but unfortunately the numbers of doctors
are not coming through. It is partly financial and it is partly
a numbers game at college level.
(Mr Jones) The infrastructure that Kate described
as being there and the standards being there for training in contraceptive
and other work, is notably absent in terms of abortion practice
and the skill base for termination pregnancy which I referred
to earlier. There is a significant issue there in relation to
the capability in future to deliver the targets that have been
identified within the Strategy for abortion care, if there is
a real commitment to do that, with the lack of skill base which
exist at the moment.
197. Just a very quick point, again about access
to services. What would you say to the assumption that by making
people more aware of the services which are available at their
GP's clinic or within the local community, particularly young
people, that would encourage them to become sexually active younger?
Is there any evidence internationally that would back that up
and if there is, should we be worried?
(Dr Guthrie) There is no evidence for that. The World
Health Organisation, and all the big authorities have gone into
this, there is absolutely no evidence. The only evidence there
is is that properly conducted education programmes and
service delivery retards the rate of starting sex.
198. Part of the reason in Holland
(Dr Guthrie) They become sexually active later.
199.you would say that is linked to the
openness of advice?
(Dr Guthrie) Education, environment and service delivery.
14 Note by witness: Manpower planning/manpower
census available from Faculty of Family Planning. Back