Examination of Witnesses (Questions 200-219)|
JOHNSON MP, MS
10 FEBRUARY 2005
Q200 John Austin: Can I just come back
to something on the GP contract and GP services in relation to
contraceptive services? The FPA in their evidence suggested that
the GP contract's lack of quality points for the provision of
contraceptive advice undermines this aspect of the contract and
does not incentivise general practice to provide a comprehensive
contraceptive service. They have also raised concerns about the
introduction of PBR, payment by results, and suggested in the
area of contraception, as an example, it could militate against
the provision of longer acting contraceptives in favour of repeat
prescriptions of oral contraceptives instead. Would you accept
either of those criticisms?
Miss Johnson: I would have no
reason to believe that, but I would be happy to write to you on
the second point. On the first point, we have recognised through
the White Paper and through the investment that is going in that
we do think more investment needs to go into contraceptive services.
That is why we have an audit of what contraceptive services are
available going on, and that is why we have already made £1
million of investment anyway this last year to improve contraceptive
services. There is £40 million additional being supplied
to address gaps in the service on the back of the audit that is
being undertaken. We have also established a group to develop
an action plan for improvement to the services, so there is a
nice guideline being developed on long-acting methods of contraception
which we think will raise awareness and usage, and we have also
allocated money, £200,000, to support nurses to undertake
the distance learning programme specifically on contraception.
That will train 2,700 practice nurses in basic sexual health skills
and supplying of condoms and emergency contraception. There is
a range of provision going on. I think we do need to see improvements
in contraceptive services, and that is why we identified the money
to do so.
Q201 John Austin: So the audit will include
general practice contraceptive provision as well as family planning
Miss Johnson: Yes, yes.
Q202 Mr Bradley: Minister, can I go back
to Chlamydia screening? You have made some comments already on
it. We have had evidence that 45 per cent of Chlamydia tests are
still being performed using the suboptimal test. Can I take it
from your previous answer it is the intention that the NAA test
should be applied in all cases by April 2006?
Miss Johnson: Yes, that is the
intention, because the other test has many more false results
on it, particularly false negatives. We do not want to continue
to use it longer than we have to, but obviously people need to
be trained, the facilities need to be there to use the new test,
and staff need to be trained in doing so. It is like any of these
changes on national screening; you have to have a roll-out period,
Q203 Mr Bradley: That roll-out period
is April 2006.
Miss Johnson: Yes, that is the
aim, to get 100 per cent coverage, all the strategic health authorities
involved by that date.
Q204 Mr Bradley: Secondly, therefore,
if we are going to have a national screening programme, it should
apply to all ages and both sexes. You are obviously agreeing with
that, so why is the current emphasis on women under 25s and not
Miss Johnson: It is not, actually.
In the interviews I have done myself in the last few days I have
been emphasizing young men as much as young women. Obviously both
sexes are infected, otherwise the problem would not be there at
all. We need to make sure that both sexes come forward. In fact,
we have specific screening programmes running around prisons and
also MoD facilities, so there is some specifically targeted largely
at the male population, but we want to see both sexes come forward
for screening. I think the risks are broadly the same for both
of them. I do not think there is quite so much evidence of the
infertility for males but there is still evidence of a serious
risk of infertility there, as there is quite a lot of evidence
that it has that consequence for women and, because it is asymptomatic,
we are very concerned that people are tested, and it is so easy
to get treatment.
Q205 Mr Bradley: So the campaign, when
it is launched, will cover the whole spectrum?
Miss Johnson: It certainly will,
yes. I think one of the things, again, about making facilities
available: young men are not frequent attenders at GPs, for example,
and unless they have had a need to go to a clinic, are they likely
to necessarily know where their clinics are? They will know where
things like pharmacies, etc, are so we need to think about the
locations where people are going to be. We need to look and see
as well whether we can run screening through colleges, for example,
and other areas like that where a lot of young people may be gathered
in the relevant age group at the same time and do things on a
much wider scale.
Q206 Dr Naysmith: I just wonder, as well,
Minister about the concentration on under 25s, simply because
there is a lot of anecdotal evidenceI do not know of any
really hard evidencethat people are sexually active to
a much later age.
Miss Johnson: Considerably later
than 25, probably.
Q207 Dr Naysmith: We know that Chlamydia
is sometimes used as an indicator of other potential hazards and
risks being undergone. Is it wise to concentrate on the under
25s? I know it is because of the fertility aspect, but is it wise
to concentrate on the under 25s and not have a general screening
Miss Johnson: I think that goes
back to the question about the national campaign to a degree,
and I agree; I think we need to extend the range that we are covering.
It really does go up to about 30 though, the age groups that we
are targeting through magazines and holiday-related publicity,
pubs, clubs and all the rest of it. It has picked up up to the
30s. But the reason for targeting Chlamydia is because there has
been a massive increase, because people are unlikely to know they
have it, because about one in nine or ten sexually active young
women is infected with it, and probably a similar number of men,
and what we wanted to do was to actually raise awareness of it,
so that people did not think "Chlamydia" was some unusual
women's name. There was a degree of ignorance about it at one
stage which meant that everybody had heard of gonorrhoea or syphilis
or HIV/AIDS and not everybody apparently had heard of Chlamydia,
and because there were not the symptoms, I think it was right
and it is right to focus quite a lot of attention on it. But of
course, if they come forward for testing on one thing, there is
much more chance that if they have other, related needs, those
needs are going to be identified and dealt with too.
Q208 John Austin: I am just curious.
Despite the recommendations in our report, your White Paper does
not mention abortion services at all. Is there a reason for that?
Miss Johnson: Our White Paper
does not mention an awful lot of things actually. It was focused
on the areas where we could principally change behaviour by a
mixture of support, provision and education and information; an
informed choice, as it were. There are obviously a whole lot of
very difficult issues around abortion. There has been much discussion
of it. It has always been a matter for Parliament to decide what
happens with the abortion laws, and a lot of the provision around
it. We have certainly concentrated a lot more money on contraception,
which I think is the right area to put a lot of extra investment
in. We decided to leave many things out of the White Paper. It
would have been a huge document had we included everything that
technically belongs to public health.
Q209 John Austin: Abortion is clearly
a key area within sexual health services. Will it feature in the
Miss Johnson: No. The implementation
plan is focused on what is in the White Paper, so it will focus
on sexual health, where we have already made announcements, so
everything from contraception through to the national campaign
for clinics, screening and Chlamydia and so forth. As far as I
am aware, we are not planning to have any provision or any particular
reference to delivery on abortion in there. We have focused on
improving early access to abortion and we have succeeded in improving
early access to abortion. It is a matter of personal view but
I personally think it would be much better if we succeeded a lot
more on contraception.
Q210 John Austin: Can I go on to a complete
different area, charging for HIV services? There are many statements
in the media, and I believe one of your colleagues in the Department
has suggested that there is a high level of health tourism. In
particular, there has been reference to HIV tourism, but I am
not aware of any substantive research that has ever been carried
out, and the evidence from organisations like Terrence Higgins
that we have received would suggest that HIV tourism is a bit
of a myth.
Miss Johnson: It is very difficult
to produce figures. Historically, figures have not been collected
by the Health Service, over decadesnever, basicallyabout
levels of people using the service who are not resident or normally
resident in the UK. That is partly because, obviously, some of
the people who use those services are genuine touristsand
I am not just talking about HIV/AIDS here; I am talking more generally,
because it is quite difficult, again, to make distinctions between
this and a number of other things for which people need treatment.
It is impossible therefore to disaggregate data as to whether
a tourist came over and broke their foot and received treatment
through an A&E department or whether somebody came in and
received another service as a so-called health tourist.
Q211 John Austin: The evidence seems
to suggest that people who have come into the country with HIV
actually seek treatment late, which seems to suggest they have
not come here as HIV tourists.
Miss Johnson: Yes. I do not want
to join in your conjecturing. I do not have any figures to supply
you with on this. I concur with the point that it is difficult
to measure it, and we do not have reliable information. What we
are clear about is that there was some abuse going on of the existing
rules, and that is why the rules review was undertaken, and a
tightening up of the wording to deliver the same consequences
that the rules had almost all been intended to deliver before.
There has been very little change of substance on the rules, but
what there has been is a tightening up of the wording so that
they actually deliver the results that they were originally intended
to deliver when they were first devised.
Q212 John Austin: I will come on to that
in a moment, but you are really saying there is not any evidence
that the UK is likely to become a magnet for HIV tourists?
Miss Johnson: What is clear is
that if people think they can come in and, under any circumstances,
remain here for free treatment, we would become such a magnet,
and that was what we were concerned to deal with. We are a national
health service; we are not a global health service. We are here
for people who are resident, and residency is the basis of the
entitlement here, as defined normally by many of us here, permanently
resident, but there are a number of other categories of people
who count as ordinarily resident here for these purposes, and
we have made sure that those categories are very clear in the
revision that has taken place, because we did not want the wrong
messages to go out elsewhere.
Q213 John Austin: Let me come on to the
rule changes and let us deal with the removal of the 12-month
exemption. In the past, persons who have been here for 12 months,
even if they no longer had proper authority to remain, were allowed
treatment, and now that is not the case. That would include, of
course, over-stayers and maybe failed asylum seekers, some of
whom may well at some stage, through an appeal process, be regularised
and be lawfully here. Has the Government any estimate of the numbers
of people who are now no longer eligible for treatment as a result
of the change in the 12-month exemption?
Miss Johnson: No, we do not. Let
me be clear about a few things, because I think it is very easy
in this area for people to get the wrong end of the stick on it.
First of all, people who come here are entitled to free tests
and, under any circumstances, somebody here, as they are entitled
to free sexual health services, they are entitled to free diagnostic
tests, and the initial response to that in terms of counselling,
free on the NHS, and that includes anybody who thinks that they
have HIV/AIDS. So there would be no reason in relation to any
of these things why somebody should not come forward early; in
fact, what we need to do is increase awareness so people do come
forward as early as possible for testing. But when people are
coming into the country, there is a lot of evidence that people
do get tested. What we are doing is making sure that, when they
are here illegally, they are not entitled to remain simply to
get free treatment when they are illegal over-stayers. That goes
back to the earlier point, that the basis of treatment has always
been residency, and that means legal residency, and people who
have simply over-stayed, however long they have over-stayed, do
not become legally resident by over-staying. We did not really
change that, in a sense. We just went back to the fundamentals
of it, that it is residency, and that means legal residency, and
therefore, being here 12 months or more does not qualify you under
those circumstances for free treatment. Can I just make one other
point? There is still provision for easement by individual clinicians
under individual circumstances, and at the end of the day, the
decisions are the clinician's; they are not for ministers and
they are not for politicians, or for any of the rest of us.
Q214 Chairman: You do not have an estimate
of the numbers affected by this change? Have you access to anybody
else's estimate as to the numbers affected? Have no voluntary
organisations put to you the numbers that are affected? You have
no knowledge whatsoever, no guesstimates?
Miss Johnson: No, no. Obviously,
people who are being expelled are a matter for the Home Office
as well, so that is not an issue for my Department.
Q215 Chairman: I appreciate that, but
you are in contact with other government departments, obviously,
and in conjunction with them, there has been no estimate from
them as to the numbers that might be affected?
Miss Johnson: No.
Q216 John Austin: I want to come on to
this question of testing. I acknowledge that HIV testing is free
of charge to anyone, and obviously we encourage that, and most
of the organisations working in the field are engaged in encouraging
people to come forward for testing. But Terrence Higgins have
suggested to us that, where we are talking about migrant communities,
who may not be eligible for access to treatment, there is now
therefore a reluctance to come forward for testing, and Terrence
Higgins in their evidence suggested this was having a significant
impact on their encouraging campaigns.
Miss Johnson: There obviously
is a difference. The free bit of it is around the public health
risk, and the public health risk if somebody has another sexually
transmitted infection is that actually, if we treat them, that
risk goes down to zero. Actually, treating somebody with HIV/AIDS,
unfortunately, does not reduce their risk to the general population
at all. It is only behaviour change that alters that risk.
Q217 John Austin: But it is part of the
Government's policy to reduce the number of undiagnosed HIV infections
in the UK.
Miss Johnson: Indeed, and we are
actively trying to encourage people to come forward for diagnosis,
because it is only upon diagnosis that people know that they need
to change their behaviour definitively, and they can access treatment
free, many categories of people, all those who fit the ordinary
residency or who are applying for asylum whose applications are
being considered. For those who are not legally resident here,
obviously, there is not an ongoing entitlement to free treatment.
Q218 John Austin: You are not concerned
then about the evidence form Terrence Higgins that there is a
resistance to come forward for testing where there is no eligibility
Miss Johnson: We do not have any
figures that show that. In fact, what I think the figures indicate
is that there are more people coming forward for testing and for
diagnosis, and that probably, as well, the improved health outcomes
for people with HIV/AIDS as a result of the improved drug treatments
are leading people to think it is more worthwhile making sure
that they get tested early and they get put on treatment as early
as possible because that is improving their life chances, despite
having the disease.
Q219 John Austin: I might want to come
back to that later. I understand that, in the correspondence between
the Committee and your Department, the Department has made no
assessment of the likely cost or cost savings of introducing the
changes to charges for overseas visitors. Is that so?
Miss Johnson: I have already explained
that there are no figures about the numbers of overseas visitors
13 See footnote 1. Back