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Appendix A
Health and Public Services Committee
23 April 2009
Transcript of Item 5: Young People’s Sexual Health in London
James Cleverly (Chair): Good morning everyone. Thank you very much for our guests
giving up their morning to help educate and inform us about the issues relating to teenage
pregnancies and sexual health.
The background for this meeting is the concern over the state of teenage pregnancies in
London and our performance against national indicators which is not good so the fairly open
question that I would like to start off with is why are we where we are? Why is our
performance against national indicators poor? Whoever feels brave enough to step in to
that particular maelstrom first please feel free.
Hong Tan (London Sexual Health Programme): First of all thank you, Chair and
Members, for this opportunity. It is really welcome to be able to discuss the issues of sexual
health across London with you.
I think the context is that clearly teenage pregnancy is a symptom if you will of a range of
causal issues which affect sexual ill health and that, as a public health issue, is clearly linked
with inequalities and deprivation - the whole broad issue - and educational attainment: issues
which I think London as a city clearly is disproportionately affected by in terms of its
younger and mobile transient population. So I think we have to think of sexual health
within the context of the inequality agenda and it is really helpful to have been involved in
some part of the work around the Inequalities Strategy that the Mayor is developing. I
think it is core really that we have to address those inequality issues in order to address
teenage pregnancy.
My colleague, Adrian Kelly, as the Regional Teenage Pregnancy Co-ordinator clearly can
talk more about the specific details. Before I pass on to him I think, for me, issues around
sexual and reproductive health have to be looked at in the context of commissioning open
access services. So with the 33 boroughs and the 31 primary care trusts (PCTs) - all those
individual governments or agencies - clearly we need more joined up streamlined working
pan-London which can add value and not be duplicated and avoid replication of effort. So,
for example, in relation to getting key messages out, it does not make any sense for there to
be 33 different approaches when we can all add value by working together consistently.
I think that also leads to the issue of the need for clear high level strategic leadership around
sexual health for London and the need for a non-National Health Service (NHS) London
champion on sexual health. As you know in 2007 we worked around issues around teenage
pregnancy with the then Regional Director Public Health, Sue Atkinson, to pull together a
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London sexual health promotion framework which did recommend that London does need a
high profile champion that could raise the issues round sexual ill health and the range of
different settings to address the key issues.
I think, finally, good sexual health is really a no brainer! It is a quick win - good effective
prevention is actually very cost effective. We all know that £1 spent for contraception this is Audit Commission Data in 2003 - saves £11 of NHS further cost. If we implemented
the National Institute for Health and Clinical Excellence (NICE) guidelines in 2005 on long
acting reversible contraception (LARC) we would have hit the target - the teenage
pregnancy target - and across London we would have saved £17 million.
James Cleverly (Chair): Can I just jump in there quickly to ask you to clarify? You
mentioned long acting reversible contraception. In layman’s terms, what is that?
Dr Simon Barton (London Sexual Health Programme): These are methods that do not
rely on daily taking of a pill, they do not rely on putting a condom or inserting a diaphragm;
they are, essentially, injectables - so the Depo-Provera injectable of a hormonal
contraception - or an implant put under the skin which slowly releases it or the insertion of
a coil which can be either a simple non-hormonally wound coil or the Merina coil which is
very popular which also has some benefits in reducing bleeding etc.
So these are things which had often, by clinicians, only been offered to women who had had
children on the grounds, “You’re in a more stable phase of your life, now is the time to think
about something where you know you don’t want a baby for three years or whatever” and
had not in any way been targeted at young people -- partly because of concerns about safety.
I sat on the NICE guideline writing group that was chaired by Chris Wilkinson and we felt
really strongly that there were huge advantages if only it could be made more available to
younger people and some of the myths about it in relation to fertility and infection and other
things could be ...
Hence the support for LARC but the delivery -- Hong [Tan] talked about the joinedupness. As a clinician and as a clinical adviser to the London sexual health team the
differences between individual primary care trusts - some of whom want to have
contraception integrated into their sexual health services, some of whom want to keep it
separate. In fact, in some places, it is still in PCT provider arms, and in some places it has
been more integrated – which seems to rely on the views and the personalities of the
individual commissioner rather than on any joined up London approach towards much
better, simpler and easier to access integrated services.
James Cleverly (Chair): You mentioned a point with regards to the long term reversible
contraceptive primarily being thought of as a contraceptive method for older women in
stable relationships. Is there a conflict between the pregnancy side of it with regard to
hormonally based contraception and the sexually transmitted infections (STI) prevention
side of it which obviously is more reliant on barrier contraception? Is there a conflict there?
I would have thought the assumption - and I am willing to have this shot down in flames - is
that promiscuity is likely to be more of a problem with younger women and therefore barrier
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contraception more important and stability is more likely with older women and therefore
hormonal contraception perhaps more appropriate?
Dr Simon Barton (London Sexual Health Programme): Yes. I will let others come in
but that is certainly something which is greatly debated about how you enable people and
empower people and try to achieve more maturity in decision making. If people are only
going to go out and have sex next Saturday night when they know they are on a big date, or
they are going to get wasted in a club and have sex then, are they going to prepare for that?
What can you use to trigger them to want to reduce their risk?
Clearly a condom is a tangible thing that the couple can negotiate the use of but, equally, it
is not an all or nothing if you have already thought about your contraception over the next
few months. It is that preparation which is as much psychological decision making about
planning to have sex rather than the spur of the moment will you use a condom or not.
You are absolutely right to hone in on that and much of the work that is being done is about
trying to get inside the heads and the thinking and the influence of young people and I
would be really interested in others’ ...
Adrian Kelly (Government Office for London): London’s performance on the teenage
pregnancy rate compared to Britain and to other regions is 10.7% reduction since 1998
which is actually equal to the reduction seen in England as a whole and is the third best
performing region in the UK so our performance is not so bad compared to other areas.
However, under that, there are some issues. There is a distinct difference between inner
London and outer London; all but one inner London borough has recorded a significant
reduction between 10% and 30%, it is the outer London ones that have particularly
struggled and some of those are big hitters such as Greenwich and Croydon in terms of
numbers which has a disproportionate effect.
The other thing to say really is that it is measured against the Government’s target to halve
the rate of conceptions by 2010 and, on reflection, that target was extremely tough. We are
talking about trying to address cultural changes in families and in communities that maybe
are not going to be addressed in a ten year period. One of the biggest risk factors for
teenage pregnancy is being born to a teenage mother yourself and so you are talking about
inter-generational patterns of lack of aspiration and seeing early parenthood as a norm and
it is proving a lot harder to make an impact on those issues than maybe we thought at the
outset.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): Hong [Tan] and
Adrian [Kelly] mentioned inequalities, they mentioned education and aspiration, in relation
to teenage pregnancy issues. Some of the work we have done locally has identified certain
ethnic groups that are at increased risk.
Adrian [Kelly] mentioned cultural issues. We have a large gypsy and Traveller community
and for them it is perfectly normal to have a pregnancy at an early age. Within the
Vietnamese community and other communities it is perfectly normal to have that. Teenage
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pregnancy in an environment that is supported by families and tradition is slightly different
than teenage pregnancy in the environment outside. I am not saying that we should not try
to reach the targets because of the community but it is something that we need to take into
account and be sensitive about because it is part of the culture and London is a multi ethnic
and multi cultural city.
There are certain pressures that young people in London have that are not the same outside
London and there is a greater pressure to start sexual activity at an early age. The media is
highly sexually charged but actually we do not talk about sex in the media. We are losing
an opportunity. The media is talking about sex all the time but in a kind of commercially
exploitative way and it is actually not talking about sex in a way that helps to prepare people
to make informed choices and that is something that is missed.
We recently, in City and Hackney, embarked on a mobile sexual health campaign. Taking
sex to the streets in Hackney and the City. The first worry we had when we were
discussing this is that you do not talk about sex. How can you have a bus talking about sex
parked in front of Liverpool Street? We do not talk about sex in Liverpool Street.
Everybody is having sex around Liverpool Street but we do not talk about it. We need to
find ways to actually be able to talk about sex in a culturally sensitive and respectful way.
And we did. We were successful in that.
That is in the area of teenage pregnancy and why London has some specific conditions. As
Adrian [Kelly] said, we are not doing as badly as we are being told that we are doing.
You posed a key question when you said about long acting reversible contraception (LARC)
and barrier methods; do these not go against each other? The issue is that actually the push
to use LARC is quite important. Yes, we will be able to reduce teenage conceptions. We
have very high rates of abortion and, in many cases, it is because women forget to take the
pill - even the morning after pill is badly taken - and LARC will obviate all of those issues.
Actually prescribing LARC does not obviate all the information about safe sex. Individuals
should make informed decisions. They should know the risks that they embark on when
they have sex; the risk about STIs, the risk about human immunodeficiency virus (HIV) and
Aids and the risk of being pregnant. One intervention does not necessarily mean that we -if everybody was on LARC in London that does not mean that we should stop safe sex
messages. On the contrary we should probably step them up.
It needs to be a multi pronged approach and we are working at different levels, not only in
health. The barrier about dealing with the schools and sex and relationship education (SRE)
in the schools, how patchy it is and how some schools still consider, “We don’t have to
implement it until 2011”.
Sexual health is a problem for young people particularly because they are more active at it
but it is also a problem with all the groups as we have seen. For many years we have
concentrated in the young groups but actually we are now seeing that 45 year old men are
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having a lot of internet sex and there are outbreaks of syphilis and other STIs related to
that. It is a broader issue than we think it is.
Richard Barnbrook (AM): Both Dr Barton and Hong [Tan] mentioned either
contraception by condom or by implant for people – late teens, club-goers, drinkers in bars.
In my borough, Barking and Dagenham, iIt is the age of 13 and 14 year olds when it is
coming in. So this may be brought up again - unless you can give an indication at this
particular moment in time - when it comes to questions on education. How does that bring
complications to yourselves when it comes to 16, 17 and 18 year olds? How does that aspect
come into the equation of how we can work with the communities outside of education at 13
and 14 year olds?
Adrian Kelly (Government Office for London): The need to get earlier education is
evidenced through that experience. The Teenage Pregnancy Unit has funded the Family
Planning Association to run a programme called Speak Easy a lot more intensively and we
have had requests from, I think, 20 London boroughs out of the 32 to participate in that.
That tends to be focused much earlier around supporting parents through Sure Start centres
and children centres to start talking about sex at a much younger age.
The age at which children initiate sexual activity actually in terms of the population
statistics as a whole for Britain - which is all that we have got really - has not changed in the
lifetime of the strategy actually, although the perception may be, through the media, that
children are having sex at a much younger age than they used to do. I think we are a lot
more tuned in to what young people are doing in terms of sexual activity than we have been
in the past and we are scrutinising a lot more closely than we ever have done. Certainly that
is bringing to the fore some things that we maybe did not really want to look at and
consider in the past.
It is also evidenced in terms of things like the Chlamydia positivity rate which has shot up.
That is as much to do with the fact that we are going out and proactively screening and
looking for it, which we did not do in the past.
Hong Tan (London Sexual Health Programme): I think the recommendation in your
original report about the need for good effective quality sexual relationship education (SRE)
in schools hopefully will be addressed with the introduction of compulsory SRE and the
development of good practice guides around that. As you know, I think sexual health is an
issue about well being and self esteem and confidence, which are skills and information
training that should be provided at an early age throughout all the good education so a cross
curriculum approach I think with integrated SRE would be most helpful.
I think Adrian [Kelly] mentioned the issues about the internet. As we know clearly a lot of
young people are accessing all sorts of information from the internet, perhaps more so than
when the original report was written. I think there are a lot of opportunities around getting
good effective interactive tools to address all the underlying issues about negotiation and
communication to have better healthy lives including sexual lives. It is an opportunity that
it would be really good to explore London wide.
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As you know, the Chlamydia screening programme is seen as an indicator of sexual health
and in London only 7 PCTs out of 31 will achieve their Chlamydia screening target at the
moment - including City and Hackney - and a lot of work that Gary [Alessio] is doing in
Westminster.
One of the great successes in London around that, initiated in London, was the introduction
of postal web access kits which has contributed about a quarter of our target in London.
Young people are sent information about accessing kits online. The percentage of young
men who access online kits that are sent anonymously to homes is much higher than
through the pharmacy, general practitioner (GP) or other schemes. So I think there are real
opportunities around interactive internet education tools.
We finally have commissioned London wide for software to be in further education (FE)
colleges. Three quarters of the FE colleges will have access to health bites. I am not really
an information technology (IT) nerd so I do not really know much about it! Apparently
once any young person accesses the personal computer (PC) in the college there will be
interactive pop ups which will ask questions - it is like a game - and they will answer. It is
quite evidence based that it does help address attitudes and social norms.
Navin Shah (Deputy Chair): Adrian [Kelly], you made a clear distinction between
performance of inner and outer London boroughs and that outer London boroughs are not
doing that well. Can you tell us the reason and what you reckon are the right measures to
overcome the gap?
Adrian Kelly (Government Office for London): In part it is statistical. The outer
London boroughs traditionally have had much lower rates of teenage conception. The one
that has performed worst is Barnet which has traditionally had very low conception rates.
So to achieve a 40% reduction on an already low baseline is quite a challenge compared to a
borough that has traditionally had extremely high teenage pregnancy rates like Lambeth,
Southwark, City and the east London boroughs as well. It is statistically easier for them to
bring it down.
hat the boroughs themselves say, including Barking and Dagenham, is that the profile of
their population has changed over the last ten years since the strategy was launched and
their population is becoming more diverse and starting to look more like an inner London
population profile and so they are not surprised that teenage pregnancy rates are rising as a
consequence. That is their perspective that I am passing on. From a purely epidemiological
basis statistically it is difficult for them to make a big reduction compared to inner London
ones.
Navin Shah (Deputy Chair): How is this being addressed?
Adrian Kelly (Government Office for London): The focus has been very much in the past
on those inner London boroughs with high rates, to bring them down. I think it is fair to
say that regionally possibly the eye has not been on those fringes of London to the same
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degree although, in terms of boroughs receiving additional support - Barking and
Dagenham, Greenwich and Croydon - have all been under ministerial scrutiny around
teenage pregnancy reporting every six months.
One of the things we are looking for this year is to bid through the REIP [Regional
Efficiency and Improvement Partnership] - the City Challenge funding mechanisms - to try
to get some intensive diagnostic and performance management support, possibly from a
private provider consultancy firm, that will work with half a dozen maybe outer London
boroughs in a collective way, sector led rather than Government office initiating it and
driving it. We want the outer London boroughs to take charge of it on behalf of a
consortium and work together to try to see how they can address what seem to be common
problems across those boroughs. But we cannot change their population.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): One of the problems
there is what we call a small area statistic. We are talking about a very small number of
conceptions so one conception could mean that you are on target or that you lost your
target. Just one. When you look at the figures in a global manner you could be saying that
they are not performing at all but when you are talking of the difference in an area where the
number of conceptions is very small, just one, compared with probably five or ten
conceptions in an area where the numbers are bigger. So that needs to be also considered in
the process otherwise they are slightly unfairly judged. That does not mean again we have
to forget about them and do not concentrate on improving performance.
Adrian Kelly (Government Office for London): Depending on your perspective that
could be a potentially good thing. We have talked already about how teenage pregnancy is
both a cause and a consequence of inequality and it is marked that teenage pregnancy rates
are higher in the areas that are more deprived. So if those areas are coming down and it is
starting to creep up slightly in some of those areas where it has traditionally been low you
are getting a levelling off so you are getting a reduction in inequality, which is no
consolation for the boroughs that are seeing their rates rise. Even when you get down to
ward level the postcode lottery for a young girl as to whether or not she is likely to become
pregnant, depending on her address, can be a chance of 1 in 100 or it can be a chance of 1 in
7 or 8, as high as that. To many people that is quite unsatisfactory.
Navin Shah (Deputy Chair): That is what I was trying to probe really and draw out
because when you look at some of the outer London areas the level of deprivation, whilst it
could be in small pockets, is comparable very much with deprivation in inner London areas.
I think it is a question of how far this is down to the numbers and the statistics. If you start
from a low base even an increase, as you said, as insignificant as one or two cases can, in
percentage terms, be much higher but then, at the same time, if deprivation and inequalities
are to do with this then this is something we need to really seriously pin down as the reason.
Adrian Kelly (Government Office for London): It is difficult because if you hear the
directors of public health in conversation with those in some of those outer London
boroughs it is clearly not -- because they are looking at borough level population they do
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not see teenage pregnancy as very high on their agenda although they do have pockets of
very deep entrenched deprivation where teenage pregnancy rates will be high.
I have heard them describe it as like looking for a needle in a haystack. It is not really
because you know exactly geographically where it is. You have got a metal detector. You
could find that needle quite easily and address it but, clearly, in some of those areas, trying
to get that message across is quite difficult when they have got other priorities. If, say, one
of those boroughs has an aging population they are going to be more concerned potentially
around things like social care provision out of hospitals and that kind of thing for the
elderly.
Hong Tan (London Sexual Health Programme): We carried out - both Young London
Matters and the PCTs in London - the first sexual health service mapping and needs
assessment and it is on the London Health Observatory website. It is the most
comprehensive mapping of needs that have been produced nationally at the moment. It is
thankfully web access so we will not kill lots of trees! There are over 400 pages of health
data there and other social care data.
One of the things you can do is there is a software system where you can compare
deprivation to, for example, teenage pregnancy or Chlamydia across London and you will
get the maps overlaid across each other. I think the key thing you will find is probably a
mixed picture - I think because it is low numbers and it is so concentrated in certain wards but there is a theme. If you look at other sexual health issues which are linked in some way
to deprivation and inequality you will see a similar map really. So, for example, round late
diagnosis of HIV you will see a similar map of more late diagnosis happening in outer
London boroughs than inner ones.
Andrew Boff (AM): Mr Tan, you mentioned the varying rates of Chlamydia screening that
there are around and it makes me wonder why there are those varying rates and whether or
not there is good practice that needs to be spread out across London. The figures I have
were that it varied between 20% in Lewisham and 1% in Ealing which seems an inexplicable
difference really. You cannot put that all down to demographics so what is not happening in
some -- without ratting on your colleagues in other PCTs?
Jose Figueroa (City and Hackney Teaching Primary Care Trust): There are different
issues that also need to be considered when you look at figures. The Chlamydia scheme has
been introduced in different ways. So some PCTs and some districts of London were part of
the initial wave of Chlamydia screening. To put it in another way; they have been screening
for Chlamydia for five years compared to others that started two years ago. That per se
means that when you look at the 20% in some parts of south east London they have got a lot
more experience and a lot more years while some of the other PCTs are learning.
City and Hackney PCT - the PCT I am Deputy Director of Public Health for - we had a
pilot three years ago and started in from two years ago and we are reaching the target; we
achieved the 17% and came higher. It has been a considerable effort and a lot of work has
gone into that. A lot of the learning from some of the PCTs that started before us came to
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help us to do that but the first year was extremely difficult to set all the mechanisms in place
to be able to screen high numbers of young people for -Andrew Boff (AM): Are we still in transition respectively with regard to these figures?
We are not seeing something that has been around for a while -Jose Figueroa (City and Hackney Teaching Primary Care Trust): Exactly. In other
words it is not a stable situation at the moment because many PCTs were fairly new. That
is not an excuse for not achieving targets but they are fairly new and 1% is a ridiculously
low figure. I completely agree with that. So that is one issue.
There has been a lot of work pan-London - and actually national work - to learn examples of
good practice and also to identify things that seem to be working but are not necessarily the
right approach to it. There has been a lot of discussion about incentives and the kind of
incentives that are used and we are now starting to pay attention to positivity rates because,
if you have fantastic incentives, everybody is going to be screened even though they have
had no risk of being infected by Chlamydia and that is not the population we want to screen.
So there is a pan-London group that is already looking at that.
Hong [Tan] has mentioned internet access and the Check Yourself website that was
started in south east London - in Greenwich and then Lambeth and Lewisham joined - and it
is not going to be expanded across the whole of London. That is one side of it.
The initial figures that counted for Chlamydia screening required that people were not
screened at the Department of Sexual Health. The argument is that a screen is a test that
you do for somebody who has not got any symptoms whereas people who went to the
Department of Sexual Health would have been screened because they were having tests
because they had symptoms. So the Department of Sexual Health figures do not count. For
example, in Hackney, a lot of our young people will go to the Department of Sexual Health
and those figures have not been counted so that somehow crippled us; because if you are
trying to reach 20% already you have got quite a lot of your population going to the
Department of Sexual Health.
Some PCTs have organised their sexual health in a different way. Sexual health is done
through community settings and people access them and those figures can be counted. So
there are also some issues about the way that services are organised that will slightly distort
the picture.
Gary Alessio (Westminster Primary Care Trust): I would agree with a lot of what you
said, Jose [Figueroa]. It shows the problem of having national targets which are
implemented locally and I think in London very often that does not work particularly well.
So for Chlamydia screening we have the same problem in Westminster as yourselves; we
have got Chelsea and Westminster with Simon [Barton] and we have got St Mary’s
Hospital all providing excellent sexual health services that our young people use, including
the ones who are asymptomatic and just want to go for a regular check up.
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We also have the additional problem in Westminster that we include the West End. We
have a highly mobile population that comes into our area and about 25% of the screens that
we carry out through our Chlamydia screening programme do not count towards our target.
So we are often in a very difficult position. We want to screen those people because
ultimately it is a public health intervention for London and it has been set up in a very
piecemeal way across different PCTs and it should not be. I think the website is a good
example of how we are trying to join that up across London so that we have one website and
one brand for Chlamydia screening but, in the past, everybody was doing their own thing.
I think there needs to be some thought about which things need to be commissioned locally,
which things need to be commissioned across London and, likewise with targets, what are
appropriate London targets and what are appropriate local targets. I know I have spent
most of last year chasing the Chlamydia target and when I do that I do not do other things.
I think you mentioned community settings. I would like to pick this up later. There is a
move to shift a lot more services into the community meaning all sorts of things including
GP practices, community pharmacy and so on. I think we should be doing that not because
it helps us meet the Chlamydia target. I am not even suggesting this. That is not the
reason to do it. The reason to do it is because it is the right thing to do, it is where users
want to access services, it improves things for the user and I think we need to stand back
slightly from chasing targets all the time and think what are we doing for our users, for our
public, young people and everybody else. I think there is a real danger that we get totally
fixated on targets to the exclusion of everything else and sometimes the targets that we
have for sexual health are not the right ones. That would be my take on Chlamydia really.
Dr Simon Barton (London Sexual Health Programme): I am very glad you raised
Chlamydia because the clinical specialists were lobbying Government since the early 1990s
about Chlamydia screening. Finally, with huge assistance from public health and with some
influential politicians - including particularly John Reid [former Health Secretary] - we
then got to a position where there was going to be a national Chlamydia screening
programme. What happened next just needs to be said for the record. There was a major
failure in the way the NHS should work. The Choosing Health White Paper came out,
highlighted £300 million being given to primary care trusts for public health in particular,
£120 million - I will not bore you with all the figures - which included the national
Chlamydia screening programme, at a time when those same people in PCTs were being
told they had to balance the books and, “You’ve got 100 days to save Patricia Hewitt
[former Secretary of State for Health]”! It was an impossible situation.
But we saw people making decisions which were purely based on finance particularly in
PCTs that did not have strong public health. If you look around PCTs in London it is hard.
There are some beacons - I know there is one - but there are some real failures in public
health in London from NHS London all the way through because there is not strength given
to that. But the Chief Medical Officer (CMO) can send out letters and the Government can
produce White Papers and say you have to do it, but you cannot make a PCT do it.
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I was involved at the time with the national support team visits - the highest performance
police of the NHS - sending out teams to PCTs who were having difficulties in meeting the
48 hour target for GMSs [General Medical Services contracts] and the Chlamydia target.
You would have people there - who were senior in the PCT - saying, “Well until I am told to
do it I am not going to because I have got a” -Andrew Boff (AM): Is it an argument for the more democratic accountability of PCTs?
Dr Simon Barton (London Sexual Health Programme): I think it is an argument for
more democratic -- it is also, from the clinician’s point of view, where we have seen things
work, it was where money was ring fenced. If you look at the moment at the way we are
moving with a lot of the Darzi reforms it is about have a clear plan for strokes, have a plan
for paediatrics, have a plan, you put money round it and you say this is how it has got to be.
Without that you have, as Hong [Tan] has said, 32 PCTs making individual decisions and
there are not 32 expert sexual health commissioners to go around, there are not 32 great
public health positions with the training, the strength and the knowledge who are going to
be there for long enough to make the changes. So it does end up often with finance directors
making more decisions about public health than certainly the clinicians and the public health
commissioners. This is where we are.
But it is clear that Chlamydia is a huge waste of money if you do not hit your targets. The
targets are not political targets, not arbitrary targets; these are targets in order to case find
enough people to meet the criteria that were given for funding the whole thing. So when as I am sure they will - the National Audit Office come and look at it, those PCTs that are at
1%, you might as well do none. I would rather they did none than did any because it is such
a waste, you are going to cover so few cases you are never going to get the benefits and that
is where the ratcheting up of the Chlamydia screening and the money that has been spent on
it is predicated on hitting those targets. I really do think that those PCTs are -Richard Barnbrook (AM): If this is the most commonsense practice signed up, a verbal
agreement between all of your bodies here, why is central Government or London
Government not listening to you and taking your advice? What is the blocking step that is
preventing you from having a common sense policy with every single PCT coming together
under one hub and sharing the resources you have got; one city, one working? What is
blocking it? What is blocking that commonsense approach? There must be some common
cause that is blocking you from doing your work.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): It sounds like a very
sensible proposal that you have suggested. I think part of it is that everybody is so busy
trying to achieve those targets that there is very little time to sit down and start developing
a strategy that is pan-London. I am trying in City and Hackney to hit the targets and make
sure that we treat and we screen the right people - which is actually quite a lot of work!
Chlamydia screening is one of the 100 targets that I have to hit and some of them - as
Simon [Barton] said - are completely ridiculous.
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I have got a target about reducing gonorrhoea numbers and I am screening for Chlamydia
and gonorrhoea. Obviously when I am screening for Chlamydia and gonorrhoea I am
detecting cases of gonorrhoea that were not symptomatic and therefore my numbers of
gonorrhoea are going to increase and anybody with any brain will know that the way of
controlling a disease is to find cases so the numbers increase and then there is a plateau
when you are still finding some cases but they do not increase, and then they start
decreasing. So to have a target that said, “Reduce the numbers” the best way of doing it is
not to look for them!
Richard Barnbrook (AM): So that means syphilis or herpes you are just going to say,
“Forget that one, I never saw that one, let’s just keep with this one”.
Maureen Boyle (Brook Advisory Centres): I will start off on a positive! There are in fact
very many young people who are very well informed and are making very good choices in
their own sexual health and contraceptive needs and working on that. I think that is what
we have to do; we have to make sure that in everything that we do that we do involve the
young people. If we involve them with the outreach work and with peer involvement they
will go out and they will speak to other young people, they will give them the information,
they will help them with the access to clinics and services and I think that is a very
important place to work from.
Also with the schools and parents -- when a young person comes into me often the first time
I will see her is when she comes and she asks me for a pregnancy test. How has she got
there? What opportunities have we not met that this is the first time that -- and she could
be 17. It is not just 13 year olds or 14, 15 year olds. How have we, in this day and age, got
to a 17 year old; the first contact that she has with a sexual health service is to ask for a
pregnancy test?
So not quite so positive.
Navin Shah (Deputy Chair): Maureen [Boyle], thank you for introducing that positive
note and discussion.
In 2005 this Health Committee looked at this very issue and published a set of
recommendations which included things like a London specific media campaign, it looked at
how flexible services to young Londoners could be specially tailored to achieve
improvement, pan-London commissioning and local targets to drive those improvements.
The question is from that period of about 2005 what do you consider to be the main tools
which have helped to drive that improvement through as far as London is concerned? Are
there specific tools like what I have said or anything else from your experience that you
reckon have worked in London to get that improvement that we are aspiring to?
Gary Alessio (Westminster Primary Care Trust): Thanks a lot. At the moment I am
Sexual Health Commissioner for Westminster Primary Care Trust. My previous job was at
Lambeth and Southwark in the modernisation initiative which was funded by Guys and
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St Thomas’ charity and was all about bringing transformational change to stroke, sexual
health and kidney services and I was in the sexual health team.
Really what we did there was to take the whole system of sexual health provision in
Lambeth and Southwark and look at what the needs were - these are areas of high need; high
rates of everything - look at what services we had and look at what we needed to do to
change those and to improve them for the whole range of people who use sexual health
services.
So developed a new sexual health centre at Camberwell which I would urge people to go and
visit; it is at Kings College Hospital in Camberwell. We were lucky; we had some resources
from the Guys and St Thomas’ charity to do this but a lot of it was not about money, it was
about actually changing working practices and people’s attitudes to things.
What we did was to redesign that service completely to provide STI and contraception
services because very often those are hugely separate; you go to one place for your STI
needs and you go somewhere else for your contraception and there is not always a lot of
interaction between the two.
We changed the way the service was delivered so when you go in you do not have reception
you have health care assistants in polo shirts with, “How can I help you?” (I think it is)
written on them which is a very friendly welcoming environment to come into. It does not
look like a traditional clinic. We have others. We have got Dean Street which I do a lot of
work with Simon on; a lovely new sexual health centre in Soho. I think that trend is
continuing; of centres that do not look like traditional health settings. But it is very
different.
What you can do there is if you have got a basic need you can pick up a pregnancy testing
kit, a Chlamydia screening kit or condoms from a machine, you can register yourself rather
than actually going to reception and basically, by registering yourself, people with
symptoms are picked out and put into a different queue so that they are seen by the
appropriate person but we do not have the fairly traditional pathway through services again I know this is changing - but where everybody goes through the same pathway
regardless of their need. You are immediately channelled into the right part of the service
so nobody is waiting there for too long and people get to see the right person more quickly.
Around that there is a whole network of services in primary care so we were using general
practice a lot more and community pharmacy because there is huge scope to develop sexual
health services in community pharmacy because it is open, it is accessible, it is open at times
when other services are not and there is a lot that can be done and pharmacists are very
willing to do sexual health work.
To cut a very, very long story short what we found a year after the clinic was opened is that
a lot more young people were using it. Numbers of Chlamydia screenings and screenings
for everything else were up, a lot more men were using it, a lot of people from black and
minority ethnic communities were using it, all the numbers were up for everything and it
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was extremely well evaluated particularly by young people. I think something like 95% of
them in the evaluation said that they would absolutely recommend it to their friends.
One of the interesting discussions that we had when we were developing that service was
about should we have carve out sessions for young people because I think sometimes there is
a real trend to think, “OK. Young people. Special group. Special need. Let’s have a service
over there somewhere on a Tuesday afternoon between 4 pm and 6 pm or whatever” and
sometimes that is used and sometimes it is not. If it is not used it is not a good use of
clinicians’ time so the idea with Camberwell was to try to have a service that was open for
everybody all the time with consistent opening hours and it has worked.
There is a very similar experience in Lewisham where they do not have a GUM clinic but
their sexual reproductive health service in the community has always done STI screening.
Historically it has been hugely well used by young people and they are very well served by
that service.
So I think that, whereas when we started that work these ideas were seen as a bit mad and
dangerous sometimes, I think they are quite mainstream now and that is great and we are
starting to do a lot more of that work in other areas too.
I think what we need is to have some vision across London again because, as a
Commissioner of Services in Westminster, there is a limit to what I can change Londonwide. Even with the services I commission I cannot make changes at St Mary’s without
talking to my other commissioners. We have to agree a vision. So I would urge any
support that we can give for some vision for sexual health services in London.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): I do encourage you to
visit the Camberwell centre. One of the things that they achieved was that traditionally
sexual health services had been at the back of the hospital in a portacabin where you know
nobody can see them and people go hidden to these services as though there is something
that is nasty about sexual health services. What they have done is the service is on the main
road with huge advertising the service about -- it is what I was saying earlier; people talking
about sex in a positive way and empowering people to make the right choices and the right
decisions.
We have a local enhanced service with primary care that is working quite well. It costs a lot
of work to do it because initially GPs -- I am a doctor and doctors we believe that we know
everything - so you cannot tell me you are paying that for a sexual health consultation
because it takes GPs half an hour to do a sexual health history. I have actually seen health
advisers - not even doctors – who can take a sexual health history in five minutes. Why? It
is because they can talk about sex. GPs are very good in asking other questions about, “Are
you depressed?” or, “How are you at home?” but, “How many partners do you have?” is
something that you feel slightly inhibited to ask and you do not ask it. So what we had to do
was to train our GPs so they are able to take a sexual health history in the same time that
they would take a history about diabetes or any other condition. That has worked.
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But then there was another barrier; the receptionists in primary care practices. As soon as a
young person - or any person - says, “I have come for a sexual health screen” they will
receive this look about, “Who are you that you have come for a sexual health screen?” So we
have to embark on a “let’s talk about sex” campaign and training receptionists that a sexual
health screen is something that is desirable and people should have access to it. That is one
issue.
For teenagers and young people they do not believe that they are vulnerable. You are
young. Disease is something that is far away. Your grandfathers suffer from disease. You
do not have any risk to suffer from disease. You do not go to the doctor. So it is not
surprising that somebody already pregnant presents at 17 for a pregnancy test because she
never considered before that there was any risk of being ill. So one of the things we need to
do is take services to kids in schools to normalise health care.
We had a couple of experiences in Hackney where we have health huts in school. We
transformed an old toilet from one of the schools into a little office with a couple of
computers and a healthcare assistant that will talk to kids about whatever they wanted.
Very often they came with what looked like a silly question, something not even related to
health and that was just an excuse to be able to go into deeper questions about the pressure
that they were having about sex, questions about contraception and other questions. Only
through normalising that contact - doctors are not these people in white coats, they are just
my next door neighbour, the person sitting next to me, and I can talk to them - can that
happen. That is, again, another area of work.
Hong Tan (London Sexual Health Programme): I think those two examples; the
modernisation initiative at Lambeth Southwark, the Dean Street clinic, which is wonderful
and the work that City and Hackney are doing, for me, symbolise what we desperately need
which is what was said about senior strategic London leadership on sexual health. When
you see that happening on a local level that is when you get those wonderful examples of
what is working.
So in terms of reports, certainly there has been some progress but I think there is still a lot
of distance to go. A lot of the recommendations in many ways still hold in terms of what we
can do better and need to do better but we do need that senior strategic leadership, I think.
When you see, for example, what Simon [Barton] said about healthcare for London and the
work round stroke and trauma services and how leadership there has really taken those
services -- sexual health has been such a Cinderella service and continues to be so for long
and yet if you ask a young person what is on the top of their mind all the surveys show there
at the top is sexual health and, secondly, issues around bullying. Yet the services are so
Cinderella. We do need that leadership and champion.
But I think also, in terms of the vision, the modernisation initiative went and talked with
young people. What Jose [Figueroa] and Maureen [Boyle] said, do we listen to what
people really say and what they need? If you ask them what they need they want quicker
access - it is all the stuff you have got in your report - but actually they want to self manage,
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they do not want to have to wait and go to a surgery or whatever, they want to go and do
the things in the modernisation initiative which has like Oyster Card machines, you punch in
something, you get your vouchers, your condoms, your contraceptive access, your kits and
then you go. Instead of something taking 2 or 3 hours it is 20 or 25 minutes. They go and
they have informed choices made through that process.
So I think we need new models of really addressing the public health issues in a much more
user friendly way around self management, around prevention, around really talking up
good sexual health rather than not addressing it and putting heads in the sand.
James Cleverly (Chair): I think we are naturally moving towards the message and the
delivery of the message which I think means the more logical thing to start talking about
here is the role of the media and the non-statutory sector in terms of helping deliver that
positive message. I will pick up the points that you made and then Maureen [Boyle] if you
want to pause for a moment because there are some questions that you wanted to ask about
the role of the media and that kind of stuff.
Dr Simon Barton (London Sexual Health Programme): Thanks. I am a doctor and I
would say this because we are practical people who like to find solutions; there has been so
much excellent policy work in this area from the Sexual Health Strategy, to the Choosing
Health White Paper, to the NICE guidance on LARC, on 15 minute consultations, Public
Health Guidance 3, NICE are coming out with work about alcohol and sexual health and
Shoreditch College Working Party on alcohol and sexual health that I chair. You could not
have more collaborative expertise between commissioners and between strategic thinkers.
Yet it has not been implemented.
You asked the question why the hell hasn’t Chlamydia screening? It is about the local
delivery methods. You said it here in Recommendation A, “Where this does not happen
future funding should be ring fenced”. You said it here about strategic leadership.
Rereading all your recommendations that Hong [Tan] has given me. They were brilliant
but they have not been implemented because they have been left to too much local fragility
around not having the skills of the people to understand what is written there and how to
achieve it.
There is also a huge mismatch in how some individual PCTs work with their NHS and their
third sector and other providers to build networks. One of the great frustrations is that
while Hong [Tan] is the Programme Manager for the London Sexual Health Programme,
I am the Clinical Lead, and there is another Clinical Lead, Chris Wilkinson, we do not have
any statutory role. We cannot tell PCTs what to do. Even when they are failing we cannot
actually do anything except cajole them, poke them, show them beacons of good practice and
smile at them and hope that they will do something, but if there is nobody in the post of
Sexual Health Commissioner there is nobody to talk to because we do not get invited to talk
to the chief executives and we do not have the power to do that. So there is a huge
mismatch between the seriousness with which you and some primary trusts are treating this.
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There is also, within London, an inherent tension: the modern NHS of contestability and “let
the market decide” and foundation trusts does not fit, to my thinking, with public health.
You would not let the market decide how to manage pandemic ‘flu or terrorism. You would
not do it. So why do we allow the market decide about Chlamydia testing or to decide about
how best to find earlier diagnosis of HIV which is also a theme and issue? Somehow public
health is more important than that. It cannot be left to 32 different people to all have a go.
There has to be much more joined up thinking. Clinicians and practitioners in the field, the
NHS and the voluntary sector want to work together and the system, at the local level, is
often acting as a barrier to that, not an enabler.
Adrian Kelly (Government Office for London): I am going back to the question about
what works though it flows through to stuff around the media. The Teenage Pregnancy
Strategy was built on a very strong evidence base, a systematic review of research around
the world at what works to bring down teenage pregnancy. About halfway through the
strategy there was a review of progress and there was a thing called the Deep Dive. The
Teenage Pregnancy Unit went in and crawled all over a handful of high performing
boroughs and a handful of poorly performing boroughs, that were statistically matched, to
tease out what it was that works in practice in Britain.
As a result of that, areas are now assessed against those ten features. There are three main
domains which are around use of data, leadership and implementation. There is a whole raft
of things around implementation.
As part of that, at a regional level, the previous regional teenage pregnancy co-ordinator has
developed a lot of resources for local areas. That is a self assessment tool kit against those
ten features. There is one on data collection, the needs of unaccompanied minors, panLondon abortion commission and guidance and, most recently, a core curriculum for sex
education across London. So this issue of some boroughs where 50% of children leave their
borough to go to school but their teenage pregnancy rate counts in the borough where they
live; this is intended to go some way to addressing -- we are hoping that all boroughs will
sign up and join on to that.
In terms of looking to the future and what is going to make a difference in terms of the
evidence base moving forward, the teenage pregnancy rates came down quite well in
America. Britain and America are right up there in terms of teenage pregnancy rates.
There is some research by someone called Santelli and he looked at whether it was
contraceptive access or whether it was abstinence only programmes which had received
federal funding in the United States. They found that the access to contraception accounted
for about 80% of the reduction in teenage pregnancy. Abstinence education not only does
not help to bring down teenage pregnancy rates, it can leave children at increased
vulnerability of certain sexually transmitted infections and, in terms of unintended
outcomes, sexual behaviours that we would not want to see in very, very young children
have increased as a result of abstinence education in America.
Going back to the issue of leadership - and we call them champions for teenage pregnancy London does not seem to have a politically elected champion for teenage pregnancy and that
17
would be a really excellent thing to see. It is at all levels though that leadership and that
championing is needed; it is at the councils, in the PCTs, in the Children’s Trust, in schools
and in communities. As Maureen [Boyle] said amongst young people themselves the use of
peer leaders and peer educators. We work with the GLA’s young inspectors around
assessing the quality of sexual health services across London.
Also, almost more importantly, about families and parents. Before we put the spotlight on
the media, really in some defence around them, whenever you look at any technological
advancement -- it is not TV actually, it is the internet that we need to be thinking about
now. Video home system (VHS) exploded because of a particular porn film. There were
these anxieties about the printing press when that came out. People will always use these
media to become sexually aroused.
I have a quotation above my desk - I have always had it - from James Baldwin. He said that
children have never been good at listening to their elders but they have never failed to
imitate them. If you look at sexual behaviours amongst the older population, the baby boom
generation, the STI rates, multiple sexual partners; the culture in terms of older people has
changed a great deal. We think role models make a big impact on young people and we
think the media has a massive impact but as the education tsar that has been looking at
discipline in schools said this week, “Actually it is how adults in families and communities
behave that has the most powerful impact on children and young people; what they do, what
they believe and how they behave”.
Richard Barnbrook (AM): I would like to ask each and every one of you to come to
Barking and Dagenham to give a presentation. I will get in contact with you individually to
try to force this through. Also with the PCTs. That to one side.
There is one aspect I would like to have clarified if I may? A quick response if Mr Tan can
give one. It is relating to education and sex education and sex relationship education. I
appreciate you mentioned you cannot take one statistic from one borough to another
borough because it has jumped, something has happened and it has gone from 1% to 4% as
opposed to 10% to 50% in different boroughs. So I understand that.
But if there is a general move with the whole society and community that both under age
sex and also sexually transmitted diseases are going to go through a younger age group,
could you inform me - to clarify in my mind - what is the idea, if it is a fixed programme, to
introduce sex education or relationship education to what I would deem as minors below an
age group that can respond consciously - if we ever do as young people - to the aspect of our
sexuality, of the body and how it functions and how we can use our body properly and keep
harmony between relationships without abusing it? Is giving sex education to five, six and
seven year olds a wise move or is it simply going to say to young people, “Become actively
thoughtful of these situations before you become aware of the consequences of misuse of
your body and other people’s”?
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Jose Figueroa (City and Hackney Teaching Primary Care Trust): I think there was a
lot of discussion in the media out of confusion. When you are talking about sex and
relationship education in five year olds -Richard Barnbrook (AM): I have seen films in my own borough with parents in schools primary schools - with the intention of showing it to five and six year olds. I think it was a
little bit too explicit for that sort of age and parents came out hopping mad.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): Locally we have the
Christopher Winter project and quite a lot of development in SRE in schools and here the
ethos is actually that it is a gradual introduction -- again it is normalising sex. It is
empowering a five year old to talk about sex whatever the concept of sex for that five year
old is. So the difference that my name is Tommy and your name is Lisa and we are different;
it is beginning with that. It is not talking about having sex as an adult would think about
having sex and using contraception at a five year old level.
The idea is to introduce it at a very early age so it is part of their every day dialogue. Kids
talk about sex amongst themselves, kids talk about sex with their parents if they are
empowered and allowed to do so but, more often than not, they are not empowered to do so
- mainly because parents do not know how to deal with a question about sex from the kids.
There are now website resources to support parents - Parent Line and other resources - to
be able to talk. Adrian [Kelly] mentioned some of the interventions to empower parents to
talk about sex with their children.
The idea is not that for a five, six, seven or eight year old you are going to have the same
message that you would have for a 16 year old. The idea is to normalise, talk about biology,
growing up and the difference. So by the time that they start thinking about sex they are
perfectly able and capable to talk to some people if they are concerned about it or they have
worries about it. The problem is that we do not talk about it. We think that children do not
talk about it. They are talking about it. They are looking at the internet. They are doing it.
Richard Barnbrook (AM): I am a teacher. I am fully aware of what goes on!
Jose Figueroa (City and Hackney Teaching Primary Care Trust): That is what I am
saying. The other things is, when you talk about SRE in the schools and when you talk to
young people about SRE in the schools many of them will say, “SRE in school is rubbish. It
is really bad” and if they were ill the day the SRE lesson was given that is it, they have lost
their chance.
What we are saying is they really value involving peers. So we have young parents who
have had babies come in to talk to young kids about their experiences. There is one exercise
of packing a bag for a picnic. It is just making them understand that, if you have a baby,
packing your bag for a picnic is a lot more complex than if you have not got a baby. That,
per se, is quite a huge deterrent because it makes you understand, “A baby is not the doll I
used to play with, a baby is a thing that I will have to take milk and nappies and whatever
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for”. They really enjoy peers or slightly their elders by two or three years talking to them
about sex. It is the issue about empowering and having the right messages.
Richard Barnbrook (AM): Where do you feel the media - through magazines, television,
radio shows and even, in this case, the internet - should play its role in bringing awareness
of the danger of unsafe sex or going too early into life and becoming a parent -- I would like
to know how this media can work? It has become a common theme from my talking to
people around London and around the country that where before people used to go
primarily with people their own age, now males and females alike are looking at people
younger than their age, especially as was referred to earlier on, people of my age - 48 - are
looking towards 16 and 17 years old whereas when I was at school you never did that; a
girlfriend or boyfriend two years younger or older was the sort of norm, your age bracket.
These things are changing. With the internet you are getting stalkers - both male and
female - looking for younger partners and with young people now becoming more mature
because society is changing they are thinking, “I’m not 16, I’m 25. I act like a 25, I work like
a 25, I think like a 25. That’s it. I’m going for that sort of age thing”.
So, again, how can the media not curtail people’s choices of relationship in consent but how
can the media work to prevent these mistakes and these happenings, going forward?
Hong Tan (London Sexual Health Programme): I think the media is hugely important
and, again, I think that is where the need for a more strategic approach across all agencies
around this to look at what parts all our agencies have to play is really, really important.
You are right. The evidence shows though that the right level of quality information, the
right development of appropriate skills and peer support in education -- there is this
wonderful DVD I will leave with you here developed by young people from a project
delivered at Hammersmith with the PCT and Brook and they are training about 6,000
young people to be peer educators. It is phenomenally powerful because one of the peer
educators is a teenage mum. Sharing her story with others really empowers others. The
evidence shows that with the appropriate information and skill base people actually delay the
onset of sexual behaviour. That is surveys all over the place.
That is the climate that the media and we altogether really need to promote that it is about
good sexual health which is definitely not about the beast, definitely not about taking
advantage of people younger than yourselves, it is about self respect, it is about
communicating wisely and about broader social good relationships. That is the key role, I
think, of everyone working with the media.
James Cleverly (Chair): Cathy [Phiri], I am not put you on the spot and make you the
spokesperson for every media vehicle past, present and future but obviously you are in a
youth oriented media organisation. Obviously the two sides of it that have been highlighted
are the potential negative impact youth oriented media can have but I would also very much
like to explore what you feel the positive influence that the media could have. So if you
could dive into that argument.
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Cathy Phiri (MTV Networks International): . I do think that we are never going to get
past the argument that the media has very negative sexual images and I do not think that is
going to go away any time soon because, unfortunately, some part of the public demands
that; that is what they want to see. But I think the media does need to be more responsible
in the messages that it is putting out there.
I was listening to what Hong [Tan] was saying earlier on; it is about having one message
that everyone is going with because, in the department I work in, which is social
responsibility, we are approached by a lot of agencies who want to put out a sexual health
message but they all want to say different things.
Young people need the simplest message. Even some of the communication campaigns that
are currently out there by the NHS are very misleading. You are not too sure what they are
trying to say. So I think the media can definitely impact on lots of young people because
young people are looking for role models, they are looking for trend setters and they want
to be aspirational as well so you can definitely use that vehicle to communicate with young
people but I think you have got to keep the messages very simple and on point and not try
to be too creative. I think now with social networking media and digital media everyone is
looking for the next big thing and they do all this really creative stuff but then what is the
message? They get so caught up in the creative side of it that they lose the message.
I think, definitely from a media point of view, we are not the ones who come up with the
messages; we are just a channel to deliver it. If, however, your sector is not giving one clear
message then it gets distorted in the media and then unfortunately the media is blamed for
it. I think that whilst there is definitely lots of negative impact on the media there is a way
to use it positively.
Also, it has to be long term. Too often they come up with, “It’s the summer. Let’s do a
summer campaign because more people are going to be having sex in the summer so we’ll do
a campaign over the summer”. People do not only have sex in the summer; they have sex
every day of the year -James Cleverly (Chair): Really! Not at my age!
Cathy Phiri (MTV Networks International): It is also targeted because that is another
thing. With MTV in particular we have different channels for different people but when we
work with some of the agencies they say, “We only want to target black and ethnic minority
communities” like they do not mix with other sectors of society. Yes, be targeted but also
remember that young people are very integrated and they mix around with a lot of people so
you cannot think that if you just target this group you are going to get your message to -that they are the only people who are being impacted, because they are not.
James Cleverly (Chair): Maureen [Boyle], could I ask you to come in - not necessarily on
the media but do not feel limited if you want to just discuss the media - on the message and
the delivery of the message? I am conscious of the fact that we have got a number of people
from the statutory NHS sector and you are an interested but detached party.
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Maureen Boyle (Brook Advisory Centres): The young people are very influenced by
media and particularly about music and that sort of thing but young people are very
involved in it so young people do lots of theatre and lots of videos and all of that so I think
there is positive and we must work with the media to get the good messages across.
I quite agree with you. Young people are getting loads of mixed messages. If we could have
something very simple and very straight; help the parents with the information, help at
school making sure that everybody gets SRE, that it is standardised to a good standard and
given over by people who are interested in doing it.
We have talked about the statutory services and wonderful places like Camberwell. The
other people we have to remember are the ones who do not access any statutory services.
Their parents never have. They never have. We have to get out there to those young
people. So it is making use of all the outreach nurses, the youth workers, go to schools,
colleges, prisons and everywhere that outreach, particularly Brook, is going.
We should be using the young people. When we are talking about new projects I have just
heard of one today with our young people involvement, in which young fathers are going to
be in barber shops and will be talking with young men - again young men who do not access
services - about condom use. Although it was quite funny in that -James Cleverly (Chair): Traditional!
Maureen Boyle (Brook Advisory Centres): What struck me as strange about that; the
barbers do not want the demonstrators. So the young fathers will be talking to people about
condom use but they will not be able to demonstrate. In conversations at hairdressers all
sorts of things get talked about. I presume barbers just as much as hairdressers. So, again,
it is these mixed messages that young people are getting, “You must have safe sex but, oh
dear, a condom demonstration is not suitable in a public place”.
James Cleverly (Chair): Cathy [Phiri], can I bring you back in? One thing whilst you
were talking that leapt into my mind - and, again, I know you cannot speak on behalf of the
whole of the media - but sex sells and that is not a modern concept at all. Is there an
internal conflict between the desire of the programme makers and your marketing people to
keep your output sexy and how does that balance between your social responsibility side
which wants to help put across a positive and constructive image about sex and sexual
relationships -Cathy Phiri (MTV Networks International): It is a really big conflict. It is a bottom line
thing at the end of the day. In the UK you have 15, 16 music channels. We have watched
some of the videos and we may think, “That is outrageous” but if we do not air it another
channel will air it and then the audience goes to that channel and we lose out on our ratings.
So it definitely is a really big internal conflict for us. What we have been able to do - even
though it is a very small change - we used to have a late hour show called Uncut, I think it
was, which was just soft porn. It was outrageous. We managed to get that taken off the air.
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On several of our channels in different markets as well we are doing the same thing. That
got taken off the air. What we are finding is the videos are becoming more and more
sexually explicit. Some of them are a bit sexually violent as well.
So we have some level standards that we have to comply with from the Office of
Communications (Ofcom) guidelines but a lot of it is how far can we push the edge of what is
going to be sexy? They look at it as in, “Well, it’s what the consumers want, we don’t make
the videos and we cannot say anything about it”.
So our department, what we try to do, is have programming that, again, is using role models
and showing young people who are living with HIV, who are dealing with their facts, so
teenage pregnancies, but when you figure how many times we show that show compared to
the music video of a man with five different girlfriends who are half naked it is just not
balancing out.
Maureen Boyle (Brook Advisory Centres): The way the young people interpret that as
well - this music - is that what you get in schools is levels of sexual bullying, inappropriate
touching, the way that young men - because they see on the videos they have 12 girlfriends - I see so much of the attitude in young men when I see them in that not having that
respectful relationship with women because, again, they are getting this mixed message
which they are interpreting and young women are complaining about being sexually bullied
at all levels.
James Cleverly (Chair): One of the questions I want to throw in is whether there is any
point in trying to desexualise the media with there being so many routes to market as it
were. Would we be better served trying to better integrate positive messages in amongst
those what you might define as negative messages rather than trying to do a King Canute
on this sexualisation of the media which has been around?
Adrian Kelly (Government Office for London): I think that it would be difficult in terms
of media control. There is always a risk of rose tinted glasses about the past and there are
aspects in terms of sexual openness that are very positive in terms of female empowerment,
for example. Certainly 20, 30 years ago it would have been quite acceptable to see sexual
harassment in the workplace or on a TV show like we saw racism on a TV show. Sexual
harassment of females certainly happened in school when I was a child and it still goes on
today.
There is some degree of media control with the TV and there is some degree with the
internet even - not as much as perhaps some might like. We are always chasing a little bit
behind as adults I think on this because if we want to see what media is possibly the most
disturbing that children and young people are seeing it is actually what is being blue toothed
between their mobile phones. What makes it disturbing is that quite often it is self made
porn rather than from the porn industry; it is images of child sexual abuse that the people
involved in it do not even necessarily believe is child sexual abuse perhaps.
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Also, on that issue of music, there is a mixed picture. Certainly some of the songs by
Dizzee Rascal [British rapper and music producer] - the lyrics - are absolutely amazing in
terms of the issues about teenage pregnancy and sexuality -- if you can understand what he
is saying because his language - although it is hard for me to catch - is very easy for young
people to catch, but one of these reports a young person probably could not understand what
it is talking about because of the jargon that is in it.
My concern about the media also is about them being an obstacle to the work that we are
trying to do rather than necessarily how can they enable us to do better. There is going to
be a big push really around sexual health services in schools. There is a constant stream of
Freedom of Information requests both to central Government, regional Government, local
Government and individual schools from particular print publications - and the Evening
Standard being one of those that stand out - and they are very hostile to the idea that
services are going to be set up in schools. It is going to start to happen and schools will get
a very difficult time and that is why we need that strong political leadership from people to
speak up and stand up for those schools that are trying to meet the needs of the children.
That issue really though about the age difference; there has always been a bit of an age gap,
particularly between girls and older boys because possibly of the maturity levels.
I think there have been a few cases recently where that age gap is quite marked and Soham
is obviously one of those ones that stands out; the behaviour of that man over a long period
of time, his interest in young women that was not really dealt with. The case of baby P in
Haringey. There was a 15 year old runaway girl living in the house with one of the older
men there. It is there as a real issue.
So we have got to ask ourselves what is going wrong around some girls’ self concept and
their sense of self value. Part of that is some of those inner city communities where it is
almost medieval where girls will become pregnant by an older man who has very, very high
status within the community because it confers on them some status within their community
and on their child.
That is why we have got to make sure, particularly on teenage pregnancy, that it is not just
about health or education, it is these cross cutting things, things like the roll out of the
common assessment framework across London for children and young people but also the
work that is going on around gangs and violence and sexual violence. I know the Mayor
recently launched an initiative around that but we have got to tie into some of those things.
We are hearing anecdotally that in some of our primary schools sexually inappropriate
behaviour by some boys - and they are from particular ethnic community groups - is driving
up things like the permanent exclusion rate which is another indicator totally unrelated to
sexual health that local areas are being performance managed and scrutinised on. So it is
very cross cutting.
Gary Alessio (Westminster Primary Care Trust): I think some of the gender issues
worry me hugely really and it feels so very different from when I was a young person a long
time ago; the kind of images that people are subjected to and the influence that that has. For
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me it comes back to we need to be working much more effectively with the schools. We
need to be developing sexual health services in schools which are not just about testing,
doing a Chlamydia screening and getting people out but about doing something much more
holistic and referring people into the right services afterwards.
The need for good sex and relationship education which is inclusive and tells you something
about sexism and some of those traditional roles that we seem to be sinking back into and
also which picks up issues for young gay men. That is an issue we have not touched on
today but we still have huge numbers of young gay men picking up HIV in London and that
is appalling and should not be happening. We are not really tackling that issue as well as we
could be and the schools need to get to grips with some of those lesbian and gay issues as
well.
Just coming back to the issue of the media, one of the things I would love to see -- we cannot
tackle some of the stuff; it is outside of our control, some of what we can see on the media.
But what we need to be doing is balancing that out with the work that we do in schools and
also with good quality information. For instance when was the last time any of us saw a
good campaign on television just highlighting what contraceptive choices there are for
women? A lot of women still do not know their different options might be. They know
about the pill because that is probably what they have been offered but they would not
necessarily know about the broader range. We need to think a lot more carefully about
what kind of campaigns we might want at national or London level to counter some of the
misinformation that people have and just think about where we can intervene in terms of the
media rather than things that are out of our control.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): One of the clearest
examples of how the media has an unbelievable impact on its readers is the recent
Jade Goody [TV personality] death. For years we have been spending loads of money,
social marketing, in how to increase cervical screening rates. Jade Goody died and the next
week our services could not cope with the number of women who wanted to be screened. It
was not even a direct message given; it was just the fact that it was a young person who died
and then conferred the feeling of vulnerability. A 20, 30 year old woman saying, “I don’t
have any problem. I won’t catch cancer”. Jade Goody died. “Oops if she can catch cancer I
could catch cancer” and then they all queued to be screened. That is one thing that we need
to bear in mind.
Now the idea of a desexualised media, I do not think it is either possible or desirable. I am
sure that we all enjoy the part of the media that has some. Some parts of the media; not the
extreme thing about abuse and whatever. The sexiness of the media is actually good, it is
welcome and we talk about things and role models are now explained. There are gay
characters and lesbian characters in the media and that has normalised. What we need to do
is balance.
Somebody mentioned about the campaign in the summer. When have you seen that
McDonald’s does a campaign for three months and then stops? The campaigns for the big
media run the whole year and they keep varying and changing the messages and make sure
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that people understand the message and take it. That is something that we have been
lacking for centuries. We really are far, far, far behind in the use of the media for keeping
the messages going. Even when we had safe sex messages they tend to appear after 9 pm
with the watershed. Very rarely are they on times when young people could have access to
these messages and they were messages that were not completely explicit or anything like
that; they were quite open messages.
On 1 December we launched a website called Show-me which is a sexual health online
website and it is for north east London. Hackney pioneered the whole development of this.
It is not entirely focused at young people because there are loads of resources already in the
world for young people. It is not focused at anybody. It does not look medical and it has
loads of different information. Since we launched it we have had more than 8,000 hits
already. Usually it is thrush and Chlamydia which are the key things that young people are
coming with worries about. More than 8,000 hits.
In that we have a little section called Ask Doctor Sarah and I was quite worried about that
because this is a section where people can type questions that they have and I just thought,
“My God, this is going to have loads of jokes and obscene questions”. No. So far we have
had 50 very clear consultations in Ask Doctor Sarah that range from a young person
wanting to register with a GP and have information about that -- you would imagine it is
not completely sexual health but probably there was some sexual health reason to be
wanting to see the GP because of the website that this person was accessing. All the others
have been serious consultations that Doctor Sarah has been able to answer. This is just one
example of using the media. In just three months that has been online.
Andrew Boff (AM): I wanted to raise the issue because the next question I was going to
ask was about young gay men and sexual health and the fact that the issue seems -- from my
perception, not being particularly young, it has just gone off the radar. To sum it up, when I
talk to young gay men they now think, “Well, you can cure it can’t you?” and it has taken
the edge off it. From an actuary’s point of view it is probably the best saving of money you
could do; persuade some of these young gay men to go back and do what older gay men have
been doing for years and using condoms. But it seems to have gone off for some reason. Is
it just not a Government priority or what is the reason?
Adrian Kelly (Government Office for London): In terms of young gay men the difference
from 10, 15 years ago is that older gay men were dying at a really big rate so - like
Jade Goody - the risk was very real and it was very there and present. Because of the
advances in medical treatment that is not there.
The same as condom use when HIV first -- when the first media campaign happened and
Britain was looking at projections where all heterosexual people would become infected on a
scale as has been seen in Africa -- condom use in heterosexuals went through the roof.
When people think there is a very clear and present danger their behaviour changes very
fast. If that risk starts to seep out of their radar their behaviour becomes less like you would
want it to be.
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I think it is unfortunate that we have got a Teenage Pregnancy Strategy that is named in
that way because the word “pregnancy” is very female focused, naturally, and it does exclude
issues of sexual diversity and it has been a challenge to get issues about young gay men on
the agenda in terms of SRE because of that. It is not about either/or. If you are talking
about the pressure that heterosexual boys are putting on girls to have sex before they want
to, well those boys are doing it not because they are bad but because they are under pressure
themselves, usually from other boys, and the pressure they are under is to prove their
heterosexuality and their masculinity - to prove they are not gay.
I used to do young men’s work in a young offenders’ institute and used to continually ask
the boys, “What does it mean to be a woman, what does it mean to be a man?” Always the
boys would couch what it meant to be a man in negative terms. It would be not to be a boy - but the number one answer was not to be gay. That is how boys and young men are
growing up and socialising as young men; to express deeply homophobic attitudes towards
other boys which includes young gay men and compounds young gay men’s vulnerability so
that when they go out and start having sex with other gay men their risk of acquiring an
infection is amplified.
Dr Simon Barton (London Sexual Health Programme): I have been in a lot of schools
and we have worked with a lot of schools and in designing Dean Street we worked with
young people and others.
I think one of the key issues is about consequences. Like the Chlamydia screening
programme. We have a test for Chlamydia. Why would I test for Chlamydia? Well you
need the information that Chlamydia leads to infertility both in men and in women, it is a
cause of mortality with regard to pregnancy, and women are three times as likely to have a
hysterectomy in their life if they have pelvic inflammatory disease. So there is a complexity.
Something that not many boys get told is that Chlamydia can cause your testicles to be the
size of a bowling ball. Those consequences of untreated infection are key to understanding
why you should do something. We sometimes do not hit those hard enough.
Clearly it used to be sexy to smoke. Everybody in film was smoking. It was cool in the
1940s, 1950s and 1960s. Then, amazingly, it suddenly changes. If you look at some of the
advertising which has been put together I am sure with huge impact and very skilled people
in the media about smoking, about alcohol and about drink driving they are incredibly
potent messages for social change which I think the law makers then come along with
maybe a little bit afterwards.
For health it has to be about consequences. Around HIV you are absolutely right; the issue
around people not dying and not being able to count a person who knew somebody and
know somebody who is terminally ill or dying of Aids is a huge step forward clinically but it
also takes away the edge and the prioritisation.
On the other hand the message for someone who is HIV positive is that it does take vast
amounts out of their psychological and physical wellbeing, it does often ultimately entail
lifetime drug therapies with side effects which affect everything from your heart to your
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sexual function to your body shape. There are huge issues there but they are complex.
They are not, “If you do this you’ll die”. The iceberg was so incredibly effective in adding to
the change of sexual health in an entire generation.
So I think it is about getting away from it being sex education and getting to being
relationship respect - as we have heard already - but health education and giving people
some understanding about what the -- I have heard a lot - and we have not mentioned it
today - the Olympics. When Tessa Jowell [Olympics Minister] spoke at a London NHS
meeting it was about this being something key to improving the health of Londoners; get
out and walk, get out and jog, get out and do this.
Also it should be about having Olympic quality sex. It should be the best. We have had
suggestions about could you get the Olympic Rings on a side of a condom. If something is
going to capture something about London and something which goes right across London
and which is sexy and which is about having highly enjoyable, highly pleasurable but as safe
as you can make it sex without health consequences for you and your partner, whether it be
psychological - as with the abuse - or physical, you start to get a definition of sexual health
that means something more than just putting it on every title on an email that is sent
between parts of the NHS and the other sector. It is more than that and people have to say
and that is why it needs a champion and some leadership.
Hong Tan (London Sexual Health Programme): I think this is a real opportunity today
to really think through about how we can get that single message approach across all
agencies. I was reminded - when Simon [Barton] talked about the Olympics - about
brainstorming about how in New York they suddenly had a culture change really in
behaviour patterns when suddenly it was really trendy to get hold of these New York
branded condoms. We were wondering if we could do something like Big Ben or something
on a condom!
There is something about how all people - not just young people - do follow trends. We
look for role models. We want to be like the people we think we should be rather than the
people we are. There is something about can we strategically get those trend setters; the
David Beckhams [England football player] and the Poshs [Victoria Beckham, Spice Girls]?
Also the young gay men. How can we get people to be the role models?
Around the Olympics the International Olympic Committee came up with an HIV
prevention tool kit which was a tool kit for athletes and the accredited workers but around
training and they do have a core part of the message. The single message was get up front
athletes to be there in their t-shirts saying, “I use a condom. HIV/STIs do not discriminate.
Be safer”. So I do think that there is a real opportunity of getting through.
We all know the effect of Eastenders and Coronation Streets. When we had a Chlamydia
screening programme through Boots, the two year path finder pilot. We all know when
those instances of someone being infected with HIV or someone coming home pregnant or
with STIs next week the activity in Boots just spiked. It is so powerful. I think there is a
real opportunity of doing something together around that.
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Adrian Kelly (Government Office for London): I forgot to mention that we are about to - the Strategic Health Authority contraception money is being used to fund the -- most of
the boroughs have condom distribution schemes for young people and because of the
mobility issue they are going to be joined up with an IT framework across London so that
the young person who registers in one borough but goes to college in a neighbouring
borough can access condoms with the same tool of access whether that is card or biometric
or whatever. One of the issues that we are struggling on is the issue of branding and the
New York City (NYC) one does stand out; that you can order them online and post cards.
There is a whole kind of media process and area of activity on it.
I just wanted to say something though about the seasonal spikes in conception; they do
happen. Being in school is hugely protective against teenage pregnancy and teenage
pregnancy does go up in the summer holidays and around Christmas. I would say - in terms
of this being the GLA - we are expecting to see some kind of spike in terms of the closure of
schools with the snow earlier in January. When you have adverse weather situations like
that you will get a spike in fertility in the whole population but you would expect to see it in
children and young people as well.
Andrew Boff (AM): It was a very enjoyable day!
Adrian Kelly (Government Office for London): But not everyone was out building
snowmen!
James Cleverly (Chair): I was about to say I just thought they were throwing snowballs at
each other but there you go!
Gary Alessio (Westminster Primary Care Trust): I think we focus a lot on the messages
and what we see on the television and role models and all of that. I was reading a report this
week that was saying about how a lot of gay men when they go to sex on the premises
venues and have sex just to see that everybody is probably HIV positive anyway so why
does it matter? That is going to take a lot more than messages that we can have through
Eastenders or through any work we can do London-wide, any of that to shift.
So I think we need a whole range. Health promotion is not just about health information; it
is also sometimes about the one to one interventions that you do in your service, for
instance, Simon [Barton], which is much more about looking at people’s behaviours and
supporting them to think differently about their lives and actually challenging some of the
negative messages that people have absorbed for the last 20 years. Issues like homophobia
are really deeply unfashionable now. We do not talk about those kinds of things because we
are encouraged to believe that the world is a lovely place and we are all equal and
everything is fair now. That is not the case and those kinds of inequalities have an impact
on people; on how they see themselves and the kind of health behaviours that we see.
I see a danger in some of the health promotion work that happens when it is about reducing
things to the lowest common denominator. It has got to be much more complex than that
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because we are all very complex beings at the end of the day and the choices we make are
affected by so many different things.
Cathy Phiri (MTV Networks International): I wanted to say what I think is really key is
normalising facts and making it OK to talk about sex. I would be really curious to see if you
do get lots of athletes agreeing to wear a t-shirt saying, “I use a condom” because the
biggest challenge we have is that whenever we do programming we want to use celebrities
because young people respond to celebrities but I can tell you the number of celebrities who
absolutely refuse to talk about using condoms and to talk about multiple partners.
We wanted to use a campaign with a celebrity who said, “Yes, I want to be involved in an
HIV Aid campaign but I am not going to talk about using condoms”. Then you cannot be
involved in the campaign because it does not make sense! So there is that whole thing that
there is still such a stigma attached to sex that we just really need to start getting young
people and all people just talking about it.
Adrian Kelly (Government Office for London): It is about bodies. The fact that you do
not see nudity on TV unless it is in a sexual context. When we get imported programming
from America and their strange norms around nudity like one of those shows where the
youngsters are running down the beach from behind and they were fuzzing out the line of
their bum where it was showing over their jeans because, in America, that would be
offensive. Those kinds of ideas that that is something you should not look at are being
imported inadvertently into British culture and children are picking up on those messages. I
think the issue about how happy you feel within your body is going to be addressed by the
media as much by being OK about things like nudity where it is a non-sexual situation. You
only ever see nudity in a sexual situation.
Andrew Boff (AM): We have touched on a lot really today. There do seem to be some keys
here and, so I feel I can understand what has gone on, we have talked about the fact that
there needs to be some kind of championing of the issue of sexual health and that should be a
high profile champion of the issue because we seem not to be having an impact on the media
front.
We have heard that targets are not entirely helpful to delivering sexual health at the ground
level and there are some contradictory criteria which are being used by the Government to
judge the performance of PCTs. There does need to be some London-wide and appropriate
responses to this.
Also normalising the very idea of sexual relationships. I do not know if that is something
we can just do in London on our own. That is normalising sex really.
My only worry is that this does seem to be - from what you have said today - quite a
centralising agenda you have talked about; when you start London-wide solutions to things
you tend to take away discretion from PCTs to meet local targets. Where is the place for
discretion and meeting local needs if you are directing everything London-wide?
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Adrian Kelly (Government Office for London): I certainly would not have subscribed to
it; I just had so many other things to say. Because the issue around ring fencing in
particular -- although there are clearly benefits to ring fencing as what happened with the
Choosing Health money which was not ring fenced getting sucked away - some areas saw
their old ring fence grant for teenage pregnancy as, “That is the money for teenage
pregnancy” and, in some boroughs, that was not going to be enough money to make the
difference. Certainly in a borough like Hackney, the local strategic partnership dug into its
pocket very deeply, taking the grant from £300,000 to £1.2 million so that local discretion
-- Whitehall or regional Government cannot always set what is needed at the local level and
you do need local solutions because the populations are very, very different around London.
Hong Tan (London Sexual Health Programme): I think, for me it is a sort of no one size
fit all really but I think the major gap is the sort of high level strategic framework which
adds value, coherence and synergy to the local work and supports the local work and vice
versa. So when you are able to say, “The brand of condom is this”. We do not have to create
one. Social marketing. We have a framework to work together on to add value but also to
push things further up in terms of the national agenda and normalising sex, “London’s take
is this; what is the rest of the country going to do about it?” So I think we need something
like a platform from which to actually be the voice of London around sexual health and we
can all work together under that voice. I do think it is “both/and”.
That strategic framework is about pulling together the best practice - we have heard a lot
about that today - and actually bringing it to a local setting and say, “We can work together
because you are local, we are all local, but we are also London”. So I think it is “both/and”.
Dr Simon Barton (London Sexual Health Programme): I hear what you say about that
tension between centralist targets and control -- as clinicians we all fight against that except
where they are good, sound, public health based targets. I think that the notion that it is key
to understand is that sexual health services, as genitourinary services always have been, are
open access, they are free and they are confidential. You do not have to - if you go to any of
the GUM clinics in London - give your NHS number, you do not have to give your real
name, you do not have to give an address, we do not care; we will see the public health. So it
is not like any other bit of the NHS. We are dealing with something so special which nearly
100 years ago people realised was special and people now, from the Department of Health to
individual PCTs, choose to forget that, as to how it has worked.
We have talked about New York and the Metro and their subway condom. We had a big
conference between the British -- the Department of Health was there, we all went out to
New York. They hold what we are doing - the NHS, the open access - as fantastic.
Yet you have situations where people think that somehow sexual behaviour ends at their
boundary. You can have two people going to a sexual health clinic and one would be able to
have an HIV test and long acting reversible contraception and the other would not. How
anybody can think, in London in 2009, that is acceptable -- we can give you clear examples
of that lack of joined up process and people worrying about their budgets and not about
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public health for Londoners. That is why you have got to have something unique for this
because it is not the same as any other part of medicine.
Jose Figueroa (City and Hackney Teaching Primary Care Trust): I give you an
example. We have one gay sauna at the boundaries of City and Hackney and there is
another one down towards Tower Hamlets, a Chariots chain. I have been supporting a pilot
project of actually testing in the sauna delivering sexual health services. It has been
amazingly successful to the point that men come into the sauna, they do not take their
clothes off because they do not want to go to the sauna, they want to attend the clinic and
then they leave. It became so successful because it is outside hospitals. They are paying the
sauna fee to go in and they are being seen. They do not even take their clothes off; they do
not want to use the sauna. So it has been extremely successful.
But, under the Money Follows Patients initiative, I have got lots of pressure about people
who go to that sauna are not living in City and Hackney so how come I am putting City and
Hackney money - which is a limited resource - to support men from other places and should
we then get information of where they live to be able to recharge their PCT of residence
which means lots of bureaucratic issues? Traditionally you did not have to identify yourself;
you did not have to give your address. Now you have to tell us where your GP is so we can
track you down and at least the first letters of your postcode so we can track you down.
That is a barrier.
When you have something that is working, that is fantastic and you are thinking, “Actually,
maintaining world class commissioning is telling me that I need to care about my
population” but actually my population could be having sex with those men who live outside
so to me that is care for my population but it is quite difficult to justify that. The pilot is
now slightly threatened because there is no way of supporting it.
Gary Alessio (Westminster Primary Care Trust): I absolutely agree with you. As a
Westminster Commissioner, given that we have got the West End, we have got your
fabulous new clinic at Dean Street and I would urge you also to go and visit Dean Street
because it is fantastic and it provides an excellent service. There is that problem that we pay
for our population. That is fine in terms of GUM services because we have a mechanism for
doing that through payment by results which is the national tariff system for how we pay for
hospital care. We do not have that for community services.
Actually what we have decided to do - and we have got a meeting this afternoon - is a group
of us have decided to get together and create an integrated tariff for contraception and STI
services and a way of cross charging that and we have decided to just get on with it and do it
ourselves because it is the only way it is going to happen! It is not going to come down to
us.
I want that because the fact that we do not have that tariff means I cannot say to
Simon’s [Barton] service, “Please provide a combined integrated service” because that is
what I really want you to do but, again, I would have that same issue of my managers
saying, “Why are we paying for all these out of Westminster contraception attendances?”
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We have got to get that thing in place. The positive message around that is that there are
enough of us around who are willing to get up and actually do it for ourselves so we do not
necessarily wait for these things to happen.
Hong Tan (London Sexual Health Programme): I think this comes back to your
question, Andrew [Boff]. That is why we need a London senior champion to think of
London and Londoners, not just individual boroughs and those boundaries.
James Cleverly (Chair): Thank you very, very much. This has genuinely been a real eye
opener for me; this meeting. I am not going to pretend - when I first had the idea of
arranging this I very much had in my mind under age pregnancies and I am glad that we
broadened this out because I think it has definitely highlighted to me the idea that looking at
these things in isolation - whether it is young gay men’s sexual heath or teen pregnancy
rates or screening levels - that cherry picking issues like that is actually really not the way
to look at this at all and I am very, very glad that you were able to attend. Thank you very,
very much.
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