Download Appendix 2 - Health Committee Transcript

Appendix 2
Health Committee
4 June 2014
Transcript Item 8: Access to Sexual Health Services
Dr Onkar Sahota AM (Chair): The topic of today’s discussion is access to sexual health in
London. The Assembly last looked into access to sexual health services in 2004 and 2005
and we focused on young people’s access to services, to information and to advice. The
report published in 2005 highlighted the hit and miss approach to information and advice, so
while some young people had access to excellent targeted and relevant information, others
did not and the lack of prioritisation of sexual health.
We are pleased to see that this issue has moved up the agenda nationally and locally. Today
we want to broaden the discussion and explore what is driving growth and demand for
sexual health services in London; how we can manage the growth and the part the
commissioner of services have to play in addressing demand; and finally what challenges the
boroughs and other commissioning parties face to ensure arrangements are put in place to
ultimately lead to improved health services and outcomes in London.
Before we begin, can I please ask members of the panel to introduce themselves, starting
from Dr Paul Crook?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Thank you, I am
Dr Paul Crook. I am a consultant epidemiologist and I work for Public Health England.
Daisy Ellis (Acting Director of Policy, Terence Higgins Trust): My name is
Daisy Ellis. I am Acting Director of Policy at Terence Higgins Trust.
Denis Onyango (Lambeth Healthwatch, England): My name is Denis Onyango. I am
representing Lambeth Healthwatch but I do also work with a community organisation in
south London.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): I am
Dr Anatole Menon-Johansson. I am the clinical lead for sexual reproductive health at Guy’s
and St Thomas’ hospital. I am also the clinical director for Brook, and lastly I founded the
Social Enterprise SXT, which is a signposting service to improve access to sexual
reproductive health providers.
Harriet Gill (Area Director, London and South East, Brook Advisory Service): Hello, I
am Harriet Gill. I am the area director for Brook, London and South East. It is a young
people’s sexual health charity.
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): I am Peter Taylor. I am the local commissioning lead for
sexual and reproductive health in Kingston in southwest London, but I also wear a hat as
the strategic co-ordinator for sexual health commissioning for London.
Dr Onkar Sahota AM (Chair): Thank you very much.
I know that Dr Crook has to leave after 30 minutes, therefore we will start the meeting with
Dr Crook who is giving a presentation on the trends of sexual health in London; and
perhaps we also can define what you mean by sexual health.
Dr Paul Crook (Consultant Epidemiologist, Public Health England): I am going to talk
broadly around sexual health and not just about poor sexual health, but also about
reproductive health, including choices that people can have around preventing unwanted
pregnancies, etc. Therefore I am going to take a broader view, not just to concentrate on
sexually transmitted infections (STI) and human immunodeficiency virus (HIV), but also
reproductive health including conception.
Dr Onkar Sahota AM (Chair): In cases of female genital mutilation (FGM) do they come
to your clinics at all?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): I am not a
clinician. I do not run any clinics. I am an epidemiologist, therefore I describe trends in the
data that we have available. I am not aware of any data that I have available, routinely,
about that.
Dr Onkar Sahota AM (Chair): This may be one of the issues that we can explore later on.
Maybe with you, Dr Anatole, later on in our discussions of how much social problems come
along to health services and also FGM. Perhaps, Dr Crook, you can set the framework for
London as you see it as an epidemiologist.
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Yes, I just wanted
to set the scene really. Thanks very much for asking me to do this. I am going to start
talking about STIs and we have a very high rate of STIs in London, it is much higher than
other regions, and about two-thirds as high as England. That means over 100,000 acute
STIs diagnosed each year.
This is looking at some of the trends by major sexually transmitted infections and we have
seen a rise in all of them over the last ten years. This is just looking at Genito-Urinary
Medicine (GUM) clinics, it is not testing out in the community. We have seen a rise in
Chlamydia, but we have also seen more dramatic rises in gonorrhoea more recently, and also
a consistent rise in syphilis. Syphilis and gonorrhoea are markers of very high risky sexual
behaviour.
Going into more detail, we have seen a 5% rise overall in acute STIs from 2011 to 2012.
Looking in more detail about gonorrhoea, we do have much higher rates than England, and
this has increased markedly over the last three years; but we have seen increased testing,
improved tests, more sensitive tests, and wider extragenital testing as well. We see a
massive variation across different London boroughs, from the highest such as Lambeth, to
the lowest Bexley. A factor in this is our populations of men who have sex with men, who
constitute a large proportion of gonorrhoea diagnoses.
This is a heat map looking at London, focusing on acute STIs, and you can see these are
rates; these are higher rates in inner London. STIs are linked with deprivation. London
local authorities constitute 12 of the top 20 highest local authority rates in the country.
Acute STI rates are higher in particular ethnic groups especially black Caribbean and after
adjusting for deprivation, black Caribbean women have five-times the rate of gonorrhoea
than white women. About two-fifths of our acute STIs are diagnosed in people born abroad.
We know that there are higher rates of acute STIs in young people. They constitute about
two-fifths of cases. However, we also know that testing is very widespread and key to those
groups.
HIV is a major public health problem for London. In 2012 we diagnosed 2,800 people with
HIV. It is great that people are diagnosed and can access treatment, and treatment can
reduce their viral load which means they are far less infectious to others. However,
unfortunately, about a fifth of Londoners, we estimate, are not diagnosed and they remain a
core driver for HIV transmission.
We have around 30,000 Londoners now accessing care with diagnosed HIV, which is great
again that they can have the successful excellent treatments. However, by failing to prevent
every HIV infection it costs the health service a third of a million pounds in direct health
care costs, therefore it is quite a costly burden.
Andrew Boff AM (Deputy Chair): Sorry, could you repeat that?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Yes. For every
HIV infection, once diagnosed, it is £320,000 estimated in lifetime direct health care costs.
Andrew Boff AM (Deputy Chair): Lifetime, £320,000 cost?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Yes.
Londoners make up about a half of all people in England living with HIV and what is still a
concern is that two-fifths are diagnosed late; which means they have worse mortality, worse
morbidity, but also they cost the health service more as well. This is just trying to make
stark the high prevalence of HIV in London. This is London sized by the rate of HIV and
you can see it dominates the English landscape in HIV.
Looking at trends for HIV, it is important to separate the different epidemics we have, men
who have sex with men (MSM) and heterosexual transmission. The top line here on the left
that is going down is the decline of heterosexual infected cases over the last ten years. This
is not particularly due to successful prevention, but because of changes in immigration
patterns, primarily we consider that to be the case, because the majority of these cases are
black Africans here being infected abroad.
On the other hand, the second line down, which is on the rise, are infections acquired
through sex between men, and you can see this has steadily increased over the last ten years
and more dramatically so in the last year that we have data available. The majority of those
are acquired in the United Kingdom (UK).
This is a heat map of people living with diagnosed HIV and again the highest rates are
towards the inner London areas, reflecting populations of both men who have sex with men
and black Africans. Black Africans constitute about a third of new diagnoses of HIV and, the
rates of HIV and those actually diagnosed with HIV are much higher in black Africans in
London.
I want to focus on MSM because that is where I think I have the most concern around poor
sexual health. 1 in 12 MSM in London have HIV. That is very high and the HIV diagnosis
is increasing in key STIs in this group, gonorrhoea cases over the last few years have more
than doubled. Syphilis diagnoses up by 60%. We know that gonorrhoea resistance is higher
in this group as well. We have also seen outbreaks of Shigella, a gastrointestinal infection
and Lymphogranuloma venereum (LGV), a Chlamydia infection, in recent years. The
majority of these cases are HIV-positive. There have been links to recreational drug use in
these rises.
Andrew Boff AM (Deputy Chair): Sorry, LGV is what?
Dr Paul Crook (Consultant Epidemiologist, Public Health England):
Lymphogranuloma venereum. It is a Chlamydia infection, quite unusual up until ten years
ago.
I thought it would be useful to highlight, to start, the disproportionate affects of poor sexual
health of MSM in this slide. In this slide we are plotting the proportion of all in London.
MSM constitute 2% of the adult population in London and over half of new HIV diagnoses,
eight out of ten Syphilis diagnoses, are in MSM. Six out of ten gonorrhoea diagnoses are in
MSM.
On a more successful note, we have seen a decline in teenage conceptions over the last ten
years, in London, as well as the rest of the country; and we now have a lower rate. However,
there is still quite a lot of variation in different boroughs. Variation is mapped here, the
colour constitutes wards with a significantly higher teenage conception rate scattered across
London, possibly linked to more deprived areas.
The abortion rate is also declining in London, however it still remains higher than the
England rate, and we still see quite a lot of variation across boroughs. If you look at the
General Practitioner (GP) prescribing of long-acting reversible contraception, the rate of
prescribing of that is much lower than we see in England.
We are working together to address poor sexual health. The London Sexual Health Group,
chaired by the Camden chief executive, are currently developing a London Sexual Health
Strategy. As you are aware, local authorities have jointly funded the new pan-London HIV
prevention programme, which we are shaping at the moment as well. London’s
commissioners network that Peter [Taylor, Sexual Health Strategic Commissioning
Coordinator, Association of Directors of Public Health] co-ordinates regularly meets.
Public Health England underpins this, providing evidence around HIV testing and
Chlamydia testing, local intelligence to identify needs, and also identify priorities. We are
going to publish a strategic framework for MSM later this month as well.
In summary, I have shown great variation in sexual health across London boroughs.
Hopefully I have shown that the burden of STIs and HIV is very high in London. We know
the key risk groups for STIs are young people, black African, black Caribbean, and MSM.
MSM do suffer particularly poor sexual health and I believe this is worsening. We have
abortion rates, which are higher than the rest of the country, but these are on the decline
and teenage conception rates are on the decline as well. Hopefully that gives you a snapshot.
There is an extra slide there at the back, just in case people want to talk about what is
different in London compared with England. Thank you very much.
Dr Onkar Sahota AM (Chair): Thank you, Dr Crook. You have illustrated to us that
London has a wider burden of these diseases, but what are the causes? What is driving this
up and why is London doing particularly worse than the rest of the country?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Partly it is to do
with the different population in London. London is a metropolitan area, the levels of
deprivation are higher and it attracts different ethnic groups. We have a large population of
MSM in the capital. Therefore, all these factors mean it is not a surprise to see higher rates
of STIs in London.
Dr Onkar Sahota AM (Chair): To what extent is there a higher rate which may be partly
due to the fact that there is more testing done of these conditions; therefore is it just down to
we are even more aware of these conditions and are going for testing, or is there something
else underlying this rise?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): I think it is great
that people are testing more, more sexual health screens are being done, and if you look
across the board HIV testing is up, sexual health screens are up. It is quite difficult to
unravel what rises are due to increased testing. The data we collect has changed over the
years. Also, if you see an increase in testing, does that mean it is an increase in testing
people who are most at risk or people who are very low risk of infection? Undoubtedly, with
Chlamydia, we have seen a huge increase in testing, therefore it is not a surprise to see the
rates of Chlamydia infection go up; you would expect them to go up, and you would hope
that the diagnostic rate would increase to make sure that those people that are infected get
the treatment they need.
With regard to Gonorrhoea infection, there have been changes over the last few years in
diagnostic tests. People are using more-sensitive nucleic acid amplification tests (NAAT),
people are more inclined to use dual testing with Chlamydia, so tests for Gonorrhoea at the
same time, with NAAT testing. We have also seen guidance from a few years ago, 2010,
which has meant that GUM clinics are more likely to test exogenital sites for gonorrhoea
with these tests as well as more tests. Therefore that explains some of it.
I think, for MSM, it does not really explain the rises that we have seen. Looking at the
gonorrhoea testing, sexual health screening data, it looks as though the tests have gone up
by around 50% over the last two years, however the number of infections has more than
doubled; and that is in the context of outbreaks of LGV, as well as Shigella, as well as an
increase in HIV. Therefore, if you put it all together, it appears that there is a worsening of
sexual health, particularly in MSM. For other risk groups, I am not so sure that the rise
cannot be explained away by increased testing.
Andrew Boff AM (Deputy Chair): Just before I ask my question, I was curious that you
have made a breakdown here about ethnicity and sexual practices. However, you have not
made an analysis by income. Is there an analysis about infection rates according to income?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Not routinely
done, therefore I do not know of any analysis like that, however mainly because we do not
collect income information in our routine surveillance data.
Andrew Boff AM (Deputy Chair): Ok, it was just something that occurred to me while I
was looking at the data.
Dr Paul Crook (Consultant Epidemiologist, Public Health England): We looked,
however, at gonorrhoea across London, looking at our surveillance data, and we tried to
adjust for levels of deprivation; and that is using an indicator, which includes employment as
part of it. However, splitting off income per se, no.
Andrew Boff AM (Deputy Chair): All right, so you have made an allowance for that
within the figures for gonorrhoea, are you saying?
Dr Paul Crook (Consultant Epidemiologist, Public Health England): This is in a public
study, which is not reflected in the presentation I have given here, but if you look at
gonorrhoea in the capital and you look at risk factors for it, living in a more deprived area is
still a significant risk factor. Being in a black Caribbean ethnic group is still a significant
risk factor for having gonorrhoea, even after you adjust for prevalence of deprivation.
Andrew Boff AM (Deputy Chair): You have given us that very useful snapshot of where
we are with regard to sexual health. I was wondering, Dr Menon-Johansson, whether or
not you have a take on the presentation that we have just done, or your aspect to it, how you
see it?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): The data fits in
exactly with what we are seeing in the clinic. In Guy’s and St Thomas’ hospital we are
diagnosing 10% of the Gonorrhoea in MSM in the UK, and that is an estimate. We have not
changed our diagnostic platform or testing in the last five years, when we have seen this rise
in Gonorrhoea, therefore it is definitely a real increase among MSM. Yes, it fits in with that.
We are also currently seeing the results around the drop in abortions, teenage pregnancies
and abortions, in that younger group, which is a legacy of the Teenage Pregnancy Strategy,
which is great.
Andrew Boff AM (Deputy Chair): Therefore the professional consensus is that we can
probably put to one side that these rises are as a result of improved reporting and improved
testing; that there is a genuine increase among certain groups, or among all groups?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): In certain groups,
certainly, we are seeing a faster rise, however Chlamydia diagnoses, for example, is very
much age dependent. Brook sees a lot of younger clients because it is a charity, it is only
allowed to see people up to the age of 25; and we are seeing a lot more Chlamydia diagnoses
than we do, for example, in the sexual health clinics that are seeing older women, and we are
comparing the two. Certainly a lot of the risk factors outlined are key. In young people we
are seeing more Chlamydia for certain.
Is it going up in general? Well of course there is a crossover with certain groups as well.
There is some link between the MSM community and others, and there are others who are
classified as heterosexual, however they have not revealed that they are sleeping with men
as well; therefore the data is as good as we can get it, however of course it is not perfect.
Andrew Boff AM (Deputy Chair): We used to talk about infections among gay men, we do
not do that anymore, we talk about MSM now. Is that correct?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): Yes, that is
correct.
Andrew Boff AM (Deputy Chair): Therefore we are seeing a significant increase in certain
groups, MSM, young people, those of African heritage. What is driving the increase? What
is the opinion of pretty much everybody of why this is happening? Who wants to go first?
The big ‘why’.
Harriet Gill (Area Director, London and South East, Brook Advisory Service): As
Dr Menon-Johansson said, Brook supports young people under the age of 25, therefore we
run clinics across London, drop-in clinics, and education programmes within schools. The
legacy of the Teenage Pregnancy Strategy is that when access to contraception and
education is improved, and where organisations and commissioning authorities work well
together, you can have a dramatic effect on rates of teenage conceptions. Generally, the idea
is that, as any age group, the more confident you are, the more equipped you are with
information, the less likely you are to take risks. However, by contrast, the STI rate among
young people for Chlamydia remains the dominant issue for young people. Chlamydia and
possibly Gonorrhoea is on our radar much more perhaps than HIV and other conditions in
Brook. Young people are taking risks still. They are still experiencing very predictable
problems with negotiating safer sex in relationships, for instance. They are taking risks just
because they still do not feel confident about prevention and about having open
conversations about discussing condom use with a partner and so on.
Andrew Boff AM (Deputy Chair): Why is that? I remember back to the Iceberg adverts
(1986) for HIV. They were very controversial at the time because it talked about sexual
activity. Now we are definitely talking about sexual activity. It is not as though there are
an enormous number of barriers to talking about sexual activity and prevention. Why are
we seeing that lack of assertiveness among young people to start taking control over their
own sexual health?
Harriet Gill (Area Director, London and South East, Brook Advisory Service): I think
the message got through, however, society’s attitudes towards sex is very, very complex.
We actively promote the sexualisation of young people, children in technical terms,
therefore the message we give is, “Bare all”, and on the other hand, “Do not do anything
before you get married”; the extremes are so broad, therefore I think the message is still
confused.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): Could I add to
that. The National Survey of Sexual Attitudes and Lifestyles (NATSL) that has just come
out as showing that people are having their sexual debut at a younger age. There is more
partner change. There are more people reporting same-sex relationships. Therefore we are
definitely seeing a change over the last 20 years in sexual activity. There is certainly a lot
of sexualisation within the media. The biggest industry on the internet is pornography.
There are big drivers there. For MSM on top of the fact that HIV is less of a threat now to
that community, thanks to the advances in the science and the life expectancy is approaching
normal for these individuals, it is still an important infection. The lifetime costs area is a
third of a million pounds, as you heard described, however they are much higher if people
present late and are diagnosed late.
However, still, that community is not threatened by HIV as it was. Back in 1996 we had this
nadir in Gonorrhoea. It was the lowest we had ever recorded in history because people were
dying, people who were transmitters within that community were dying and people were
very scared. However, those days have gone and therefore we are now in a situation where
we are back to where we always were. Lambeth and Southwark, where we are today, they
have always had a great history of theatre and brothels and all the other exciting things that
happened on the South Bank; and sex is something that is part of everybody’s life and sexual
health is an aspect of that.
Also, with MSM the internet is facilitating people meeting up more readily. There are a lot
of important reports like the Sigma report on Chemsex, so people using chemicals, such as
amphetamines, stimulants, and having more sex than they would have ever had before.
With condoms, we can promote condoms, but there is a failure rate for condoms for
contraception; so if 100 couples use condoms for a year for contraception, 15 out of 100 will
fall pregnant with typical use. With perfect use it is 2 per 100, but with typical use it is 15
per 100. Why is that? Because you run out, because they break, because it gets in the way
of what you want to have, which is sex. We can talk about it, but if you have more sex, but
you run out of condoms, then you are back to the same risk. Therefore, I think that is the
paradox, we are talking about more sex and we are promoting condoms; however people are
running out of condoms or people have problems using them, they break or they do not put
them on for the whole period of sex.
Daisy Ellis (Acting Director of Policy, Terence Higgins Trust): As far as young people
are concerned, everything that everyone says is absolutely spot on, however the one thing
that we are not doing is adequately and systematically and comprehensively providing goodquality sex and relationships education in schools. Therefore we have new waves and
generations of young people coming through into adult life that simply do not have those
negotiation skills, do not have the confidence to figure out how they want to have a healthy
relationship, how to negotiate safer sex, and they are finding information from a variety of
sources, not all of which are reliable. That is one of the biggest challenges that we have. It
is our best opportunity to give young people up to date accurate information, however it is
simply not happening across the board. Ofsted reports have reported as such, that there is
not standard education being provided and it is not good-quality sex and relationships
education. It feeds into young MSM communities as well because we are not giving sex and
relationships education across all sexualities. Therefore, we have young people going
through and they might have a lesson that touches on HIV in biology, however they are not
always given that rounded constant education stream throughout their school years at ageappropriate points. Therefore it is about providing that age-appropriate education, building
up confidence, so that it is not just a standalone biology lesson that is thrown in, in year 10
or 11, or one phase in their education, but we build that confidence up.
Andrew Boff AM (Deputy Chair): It is certainly not the absence of leaflets and posters
with regard to young MSM, they are in abundance, and the information is in abundance,
however it does not seem to be followed.
Daisy Ellis (Acting Director of Policy, Terence Higgins Trust): It is not built in,
therefore I think it is about adding it on at a certain point. That comprehensive knowledge
base and confidence level is not built up through education at the moment. We are not
having discussions about same-sex relationships and heterosexual relationships and what is
healthy and what is not and how to negotiate different things. Then all of a sudden people
find themselves in a real-life situation and yes they have information thrown at them,
however they do not necessarily have that confidence built in them. They are kind of dealing
with a whole range of emotional issues, and unless we can get those issues addressed so that
young people grow up feeling confident, self-assured, with good knowledge of where those
good-quality information and resources are; then we are not giving them the best chance in
life to go on and have healthier sex and relationships and safer sex in their adult lives.
Denis Onyango (Lambeth Healthwatch, England): Just adding to what Daisy just said,
Healthwatch Central West London carried out research into sexual health education needs
of young people and discovered that a huge majority of those interviewed responded as not
being aware of where services can be accessed. For example, 44% did not know where to get
emergency contraception; 63% did not know where they could get help around healthy
sexual relationships; and most of them preferred that sex and relationship education in
schools should include issues like domestic violence, sexuality, and look at various factors
within that whole framework. The traditional provision of sex and relationship education
within schools, maybe, should be looked at again. There are experts out there, there are
organisations like Brook that are quite good at working with young people, who are focused
on providing a wholesome approach to health for young people. Maybe it is high time that
we explored some of those strategies to try to get everyone to play their role.
Coming back to the needs of communities, the increase especially for us in south London
where we have a significant number of ethnic minorities, you find that the traditional
approaches of HIV prevention or sexual health promotion have not worked. You find that,
much as we appreciate the investment that has gone into both clinical and public health
interventions, there are communities like the French-speaking African communities that are
largely ignored when it comes to sexual health promotion. Faith communities, the
organisation I work for which is called Africa Advocacy Foundation, do some great work in
trying to get imams [Islamic leaders] in mosques trained to be able to tackle sex and
relationships within their congregations; and that worked very well. But I find that, if you
look at the level of engagement of faith leaders now, it is quite minimal and that is also
supported by the investment that goes in to supporting faith interventions in sexual health
promotion in general.
If you look at Africans, especially the young African people, most of them are being brought
up in the traditional church kind of setup, and if you go to evangelical churches in London
you find a significant number of African and Caribbean young people. However, they are
getting conflicting messages in that the church says you cannot have sex before marriage,
when in fact most people are sexually active. Therefore issues like access to condoms are
quite conflicting, should they access contraception or should they not? Therefore I think we
need to go back to the drawing board and look at how we can meaningfully engage the faith
leaders, train them, and get them active in promoting sexual health.
Andrew Boff AM (Deputy Chair): Has there been an analysis - I mean I asked earlier
about income - about infection rates among different faiths?
Denis Onyango (Lambeth Healthwatch, England): I do not think there has been,
however the experience we are seeing, based on the interventions that we are having,
indicates that faith leaders could play a very important role. I know in the media there has
been the issue of faith leaders stopping people from accessing HIV medication and that is
true for some cases, but that should not prevent us from engaging with faith leaders and
making sure that they play their correct roles in promoting sexual health.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): From NATSL not the recent one, but the one previously - the group with the least infections were the
Muslim community and there was less partner exchange within them. Therefore it is
dependent on how many partners you have and it is about sexual networks and Professor
[Geoffrey] Garnett [Professor of Microparasite Epidemiology at Imperial College London]
has modelled this very well for Chlamydia, and it is true for other infections. The more
people you test, you end up getting into a virtuous circle where you drive down the
infections because you get enough people testing within the sexual network. However, if
you do not test enough people within the sexual network, then you are in a vicious circle
where you do not find all the infections and they carry on transmitting.
Therefore the extension of this analysis is that, if we test more people, we are going to have
the opportunity to deal with the epidemics. However, if we do not get people in to test, we
will carry on having these epidemics spreading within the communities, and that is what we
need to think about.
In terms of deprivation and STIs, we moved from the Lydia Clinic at St Thomas’ hospital to
Burrell Street, which is only a short distance, still ten minutes from Waterloo Station,
however we saw a significant drop. We halved the number of black African and black
Caribbean patients coming through Burrell Street compared to Lydia, which is about
100 patients per week. The reason is there were 12 buses that crossed Westminster Bridge
coming from Lambeth and Southwark and there were only four going over Blackfriars
Bridge, which is our nearest bridge, and most of the poor people use buses for transport.
Therefore, when you look at deprivation and access to services, you have to think about the
routes of where patients are moving to access these services; and that is a real challenge
when you are thinking about commissioning services, where they are located, and improving
access to testing.
Dr Paul Crook (Consultant Epidemiologist, Public Health England): I just wanted to
focus again on MSM before I leave. I think that, given that the main driver for rises in STIs
are in MSM, we need to think about the seroadaptive behaviour among MSM. Which is
essentially that an HIV-positive man might choose to have sex with a partner who is also
HIV-positive, somebody HIV-negative choosing their partner who is HIV-negative, or who
they believe is HIV-negative. There are several knock-on effects of this. We have the HIVpositive MSM that do not think they are at risk in terms of getting HIV. Therefore they do
not wear condoms, therefore this means they get Syphilis, Gonorrhoea, LGV, Shigella
infections and, as demonstrated before, we are seeing a much higher percentage of these
infections among HIV-positive MSMs; so rates of those STIs are much higher in HIVpositive MSM, which means that they are not using condoms because they do not think
there is a risk in terms of transmission of HIV. The things that they are worried about, I
believe, are things like Hepatitis C. Other things they believe can be treated simply with
antibiotics, unlike back in the 1980s with the Tombstone campaign when HIV was
untreatable.
For HIV-negative men, this is a problem, because if they choose to have sex without a
condom with another HIV-negative man that person may have HIV because I have
described that one in five people with HIV do not know they have it. Therefore, even
though the other person might believe that they do not have HIV, there is a risk there.
Also, they get the risk of all the other STIs as well.
Therefore this seroadaptive behaviour or sero-sorting, as it is called, is a really important
driver around STIs in the capital, because these people do not wear condoms. If you look at
some of the surveys, people say they have access to condoms, however, only 40% of MSM
used them the time they had sex. It is not because they do not have condoms around,
according to the surveys. Therefore this is an important component, which is I think is
important to either for transmission, because these are the real core group. They are the
ones with Gonorrhoea and Syphilis, which, to get Gonorrhoea and Syphilis you have to have
a lot of risky sex. Chlamydia, a lot of people may get Chlamydia because they do not have to
be part of a core group, because it is easier to transmit.
Dr Onkar Sahota AM (Chair): Thank you very much for your time, Dr Crook.
Dr Paul Crook (Consultant Epidemiologist, Public Health England): Thank you very
much.
Dr Onkar Sahota AM (Chair): We really value your contributions this afternoon and
thank you very much for making the effort and coming here. Thank you.
Andrew Boff AM (Deputy Chair): I am quite interested in what you said about young
people and about how we get young people to be more confident about choosing safer
practices. Are there any examples of good practice that we could look at?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): In Holland, they
talk about sex at an earlier age. Well, it is the whole of Europe, but Holland is the best
example, - and they start having sex education at primary school age in Berlin. I met an
English man recently who has moved over there and he was describing that. It is ongoing.
It is a conversation, it is not just one lesson and that is it, tick the box.
Dr Onkar Sahota AM (Chair): From what age?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): I am not sure
which age it was, however, it is before they are sexually active.
Dr Onkar Sahota AM (Chair): Therefore it could be in primary school?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): Yes. Therefore,
talking about sex in Holland delays sexual debut and that data has been around for two
decades.
It is the same about talking about drugs. The argument is, that if you talk about drugs, you
talk about condoms, you talk about sex, people are going to adopt these behaviours earlier.
The evidence from Holland has been clear for two decades that it is not the case. However,
it is still cited in the media that if we talk about sex that we are going to harm our children.
We are not. We are going to empower children and they will make more sensible decisions.
That data has been there for a long time and it is very frustrating for people involved in
education to then have to respond to the ideology that some people have, which is not
evidence-based. However, that is certainly a true fact that has been in the literature for a
long time.
Harriet Gill (Area Director, London and South East, Brook Advisory Service):
Talking about examples already happening within London, within Lambeth, the local
authority funds a combination of clinic support services for young people, not just Brook,
but other services as well, and education in schools. An example of a really effective
approach that is well evaluated and, as you can see from the presentation earlier, the
statistics for Lambeth’s teenage conceptions is dramatic, with a huge decrease in unplanned
pregnancies among young people. There is an approach that Brook takes in schools called
Bitesize Brook where we go into usually secondary schools and work with whole year
groups on different learning zones. They spend a period of time moving around learning
zones, around a whole range of sexual health and wellbeing topics, and we usually deliver
that in partnership because, no organisation can work independently – it is the reason why
we are all here today - the only way you can make interventions work early on is to work
with other people who are specialists in their area.
We also train professionals so that it is not just us. Once we leave the building, we want
teachers to feel confident, given that sex and relationships education is not statutory, that
they can deliver positive sexual health messages to young people as well; and signposting is
the most basic easy way to get people through the door. Therefore, our education team in
Brook will go into a school and then talk about what a Brook clinic looks like and what
young people can expect from Brook and what it means to be offered a confidential service
and what your rights are under the age of 16. They should not be grey areas, however, they
still are.
Young people are really worried about their rights. We approach our work from, in a way it
is backing up the United Nations (UN) Convention on the Rights of the Child, a child’s
rights approach, so that young people know that they can access services. The way that
education workers and clinic workers work is young-people friendly, positive, welcoming,
encouraging discussion, encouraging young people to discuss dilemmas and situations with
each other. It is nothing you will not have heard, it is just when it is well funded and
supported by local commissioning, it has a great effect on young people locally.
Andrew Boff AM (Deputy Chair): Do you get much kickback now from education about
sex and relationships? We used to have long arguments about certain parents wanting to
withdraw their children from classes and stuff, and no doubt there are still a few.
Harriet Gill (Area Director, London and South East, Brook Advisory Service): Less, I
think. I have been involved in Brook for a long time and I was only thinking the other day,
we used to get contacted about once a week by an angry parent, and now it is very rare.
Although young people have a right to withdraw from sex and relationship education (SRE)
sessions in school, a miniscule number of parents use that right, which is a very positive
sign. However, what happens behind that is that conversations happen with schools very
early on so that parents are aware of what sex and relationship education is about. As Daisy
[Ellis (Acting Director of Policy, Terence Higgins Trust)] said earlier, it is not about
giving an eight-year-old a condom demonstration, of course it is not, however, it is about
early conversations about friendships, about body changes, about what to expect, even when
you transition from primary school to secondary school, what that might mean. It is an
enormous change for young people. Therefore sex and relationships education is much
more really about relationships than anything else.
Andrew Boff AM (Deputy Chair): You are guided by the UN Convention and one of the
prime bits about the UN Convention, and they forget about rights of the child is in there, it
says, “Appropriate to the age of the child”.
Harriet Gill (Area Director, London and South East, Brook Advisory Service):
Absolutely.
Andrew Boff AM (Deputy Chair): It always says, “Appropriate to the age of the child”, not
you spill over all this adult information in one fell swoop. You check the maturity of the
child. I am pleased to hear that you are guided by that because it is a very strong document.
Denis Onyango (Lambeth Healthwatch, England): I just wanted to add on to that, to say
that one of the things that has been noticed, especially in south London, is the lack of
investment in other aspects which, I believe, could give sex and relationship education a
more comprehensive outlook; and that includes, if you look at the local strategies, very few
have acted on issues of female genital mutilation. I think that is something that should be
looked at in the context of this kind of education.
The Healthwatch Central West London also gives prominence to involving young people.
A piece I recall involved young people who were asked what kind of sex education they
would like to have. I think we should look at giving prominence to young people to
determine what is appropriate, because I do not think it helps anybody to go and give
information to young people on what is involved. However, I think the issue of FGM
should be looked at seriously by the relevant authorities. If you look currently, you see it in
the strategies, and we have worked very hard to get FGM into the strategies of Lambeth
and Lewisham. However, if you look at the expenditure, they spend maybe half towards
interventions and on FGM it is not there. Credit to trusts like Trust for London, Esmée
Fairbairn Foundation and Rosa, they are leading a national initiative on FGM that is also
involving families and young people and I think we could learn a lot from that.
Dr Onkar Sahota AM (Chair): When you are talking about interventions, are you
referring to educating children?
Denis Onyango (Lambeth Healthwatch, England): No, not educating children. I think
mentioning that. When you look at the curriculum of sex and relationship education,
probably there are some aspects of it that might be important. I think, however that, we
need to look at how we could include it in some of the strategies. We are seeing more and
more young champions getting involved in FGM, and certainly we have very strong voices
among young people trying to campaign against depravities. Therefore I think there could
be some influence there, not necessarily in giving the information directly to children that
may not be at risk. But I think it should be looked at.
Andrew Boff AM (Deputy Chair): We were talking about FGM prior to this meeting,
about whether or not it needs to be included as part of the sexual education provision and so
it is fascinating that you can make that contribution. Mr Dismore [Andrew Dismore AM]
was promoting the idea that we should include it.
Andrew Dismore AM: I do not think it is taken as part of sexual health services and it
should be.
Dr Onkar Sahota AM (Chair): Dr Anatole, what is your clinical experience of this? Do
you see many cases of this?
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): We do see it, and
we usually see it after it has been done and women are presenting later when they are
sexually active. The first case I ever saw was when I was working in east London and there
was terrible scarring and sequelae from that procedure. It was a grade 4 procedure where
everything had been removed, the clitoris and the labia, and that woman was having real
difficulties, as they do, in intercourse, normal vaginal health and, vaginal delivery.
We have, in Guy’s and St Thomas’ Trust, Comfort Momoh [MBE, Midwife and
FGM/Public Health Specialist], who is doing a lot of work around surgery and treatments
for those women, as well as raising awareness. However, I think the big challenge that we
have is that there has been no prosecutions around FGM. We know that girls have been
taken away and then having it performed, and possibly in the UK as well, we are not sure
how much is going on. However, when we see it in clinic, we always then ask about other
siblings who could potentially be at risk; and we always obviously ask about complications
and could we provide remedial treatment around that or referrals. The challenge is how do
you sensitively support that patient who is coming in and make sure that you can protect
maybe other members of the family; if there are younger siblings, and do that in a way that
does not threaten or ostracise that woman, because obviously we are trying to deliver a
service at that time. Therefore there is a lot of education that we deliver around that and
support services that we can link in to. However, the challenge is, how do you do it in a way
that is enabling and constructive and supportive as opposed to seen as alienating a person.
Dr Onkar Sahota AM (Chair): I recognise that FGM should be part of sex education
which children get, but where do the commissioners see commissioning services for FGM?
Do you see it as being commissioned through primary care or do you see it commissioned
through the sexual health services?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): There is no single answer to that unfortunately. I think it is
a developing issue that is unfolding for commissioners and for providers and organisations
alike. I think there are two questions, one is around where does it best sit around the
possibilities of prevention or education before FGM may take place, so educating young
people around their rights and around who they can go to and that type of information.
With regard to the clinical end of it, so it has happened and discovery of that, I think that
there are questions around where these ladies are presenting; some are presenting in GUM
services, however, I believe that many are presenting through gynaecological services,
obstetrics and what have you. Therefore, in fact, we could do whatever we wanted to
change our service specifications on our GUM provision, however that would not meet the
clinical needs once the FGM has occurred.
We do see local authorities beginning to address it, especially in high-prevalence areas. I am
aware that Waltham Forest have begun an initiative and encouraged other local authority
commissioners, where they do have it as a specific issue in their demographics, to work with
them in developing some strategy around FGM. That work has started in the last year,
therefore I think it is on the radar, if you like, of sexual health commissioners, it is
something that is being looked at. However, I think you are looking at two different things.
You have the education end and then the clinical end. The clinical end is broadly different to
addressing the other sexual health issues that we are talking about today.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): Just one thing, I
had a medical student look at information for women about vaginal anatomy. There is a
question on the Sexpression website, which is a medical student organisation around
educating around sexual reproductive health. One of the common questions on the site was
around, “Is my vagina normal?” Therefore she was looking at what is available on the web
to show what is normal anatomy; I was proud to say it was the Brook website that had the
best information. There is a paucity of really good educational materials for people to find
out what is normal and I think that is an important step. If we can broaden what is normal,
what we consider dangerous to health, and certainly FGM there is no medical benefit that
has ever been described around that, therefore it is really important that we empower people
to think that way.
Andrew Boff AM (Deputy Chair): I am trying to think the Google search that you put in
to find that. You would not get much useful information I would not have thought.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): You get a lot of
information however you have to wade through it.
Dr Onkar Sahota AM (Chair): Peter, can I just ask you this question. What proportion of
London’s public health spend is attributed to sexual health and what challenges do you or
your colleagues face in driving the discussion for commissioning and provision of services to
improve sexual local health services?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): Across London, 35% of the public health grant was spent on
sexual health in the first financial year with the transition of sexual health services into local
authority commissioning. There is inevitably a bit of a range, depending on local authority
by local authority, however, that is the round-up answer as it were. It is the single biggest
element of spending of the public health grant, second to it is substance misuse and alcohol
services; however sexual health spending is the biggest single element of the spending of the
public health grant. We spend more than average per head of population in London than
the rest of the country. Elsewhere in the country it is around 25% of public health grant
spending, however, as I say, it is 35% in London.
In terms of problems, I am aware that there was lots of concern around transition and that
there have been some issues around resolving problems that inevitably have arisen through
transition. From my point of view as a commissioner, the problems are no different on
1 April 2013 than they were on 31 March 2013; and the transition of services from London’s
point of view, and from a patient perspective point of view, has been seamless. We have had
no faltering in service offer to patients. We have no lesser access to patients in London.
There have been logistical and sort of process issues between the new commissioners and
the providers; and some of that is as simple as people getting the right names and addresses
to send their letters or indeed their invoices to. However, I do think that has begun to settle
down.
If you draw back from the services themselves and draw back further from these process
issues between commissioners and providers, what we did lose in transition was the London
Sexual Health Programme with the demise of the National Health Service (NHS) London
Strategic Health Authority and the Association of Directors of Public Health in London
have moved quite quickly. That is quite a newly-formed group of all the directors of public
health across London. They moved quite quickly to begin to address that and so they
formed a network of commissioners in London. They looked to appoint a co-ordinator for
that network, and that is a job share, I am half of that with a lady called Jane Mezzone
[Associate Consultant at NUDGE Associates] and we have begun work to look at
collaborative approaches to commissioning. For example, the leaders in London have signed
off a three-year programme for HIV prevention across the capital, so again all 32 boroughs
and the City signed up to that three-year programme. I know another question we may look
at is around the ring-fenced grant, and that is a commitment beyond the end of that ringfenced grant and therefore I think there are some important signals in the first year about
that.
Dr Onkar Sahota AM (Chair): I hear that you may be establishing this integrated health
care, sexual health tariff, between the boroughs? How is that going and have all the
boroughs signed up to that?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): What all the boroughs have signed up to is a piece of work
that will refresh the modelling that was done by NHS London to be based on up-to-date
data. The last work that was done on this was back in 2011/12 and there have not been any
reports and updates on this since the early part of 2012. Therefore we need to make sure
that the data is fresh because it is an ever-changing area. It also will be based on borough
populations, because the work done to date modelled for the whole of London was based on
primary care trust (PCT) populations; and there are significant differences. In Kingston,
quite a small borough in the scheme of things from a population point of view; I have 40,000
more people for whom I am responsible for their sexual health care based on our borough
resident population, than I did have as a PCT commissioner based on our GP-registered
practice populations. Therefore that remodelling work has begun. That will be completed
through the rest of this calendar year and we will get a report for that in the early part of
the next calendar year. Obviously, we will then need to look at that, see what risks and
benefits that offers potentially to boroughs, and that will be again another question for
leaders in London if they want to adopt an integrated tariff for the whole of London;
however the whole of London is looking at it.
Andrew Boff AM (Deputy Chair): The public health budgets are split three ways. You
can understand the functional split between them, between Public Health England, local
authorities and NHS England. To what extent does this funding arrangement hinder the
provision of an integrated service?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): The quick answer would be it does not. The gift of
integrated services very much sits with the local authorities now, as it did with PCTs.
Therefore, the money that pays for prevention, for screening, for testing, for treatment of
STIs, and other elements of treatment and care around sexual health, that has always sat in
the commissioning role of PCTs and now in local authorities. That money is wholly with
the local authorities.
NHS England commission primary care and in the core, the GP and pharmacy services. In
the core contract for GPs, they have an obligation to provide oral contraception, but their
core contract requirement ends there. In most practices, many GPs do additional services
around sexual health; however they have always been paid for in addition to their core
contract. The money for those, if you like, and the commissioning for those, have also come
to local authorities. Therefore NHS England are responsible for the core contract. We have
the ability and we are, indeed, across London, commissioning additional sexual and
contraceptive services from GPs.
NHS England also have responsibility for specialised services, so that is HIV treatment and
care, the money sits with them, they pay for that and that is discretely theirs. The
interesting thing with that is, in the main, the infrastructure for the HIV treatment and care
services in the main are GUM clinics. Therefore the infrastructure for HIV treatment and
care is dependent on local authorities, because local authorities procure the GUM clinics
that that HIV treatment and care service sits in.
Therefore the obvious need for good communication and for collaborative working, and
again with our Public Health England colleagues around knowing which populations where
we need to address issues in and getting information back on whether we are getting it right
and all of those things, is very clear; however it is not a hindrance to a move towards
integrated service.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): The biggest issue
around NHS England funding is the piece around cervical screening. Yet there are a lot of
women who present to sexual health services, who do not have a GP, who require cervical
screening. There are moves to try to push a lot of women into general practice, however of
course there is a need for some women to be screened within the sexual health services; and
certainly women do complain that they cannot get a cervical smear when they are having
everything else done in the sexual health service. Of course that is an issue that has come
out from this three-way split and there are moves to try to remove cervical screening from
sexual reproductive health services because of that different funding pool. I think there is a
chance that we are going to miss women, it is the best screening programme in the UK, and
it is the one that we need to really support. That is the only issue that has really come up
from the three-way split.
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): The cervical screening issue so far appears to be quite
discrete to certain commissioners or certain areas. Speaking as a local commissioner in
Kingston, some cervical screening does take place, in our integrated GUM clinic. That is
part of our requirement on them of the service that we commissioned from them and that
continues. Before transition, of all the cervical screening that happens across England,
about 95% of cervical screening takes part through the commissioned national screening
programme; therefore providers who offer that receive payment for being part of that
national screening programme. About 5% of cervical screens across England occur outside
of that screening programme. A woman has presented to potentially a GUM service and
has either requested or there is something identified by the clinician or there is a
conversation where the woman says, “Well I have not attended my last three invites for a
cervical screen, for a smear”, and the cervical screen will be offered.
What has happened from transition, as you mentioned, is that in some areas there has either
been a misunderstanding or a disagreement between what the payments for services
represent, what elements of care you should get within that payment, and what is an
additional service for which additional payment should be made. However, it certainly is not
an issue everywhere and certainly, for example, in Kingston it is not an issue. I take the
point and I am aware of the ongoing conversations around it, however, I would not like
people to believe that it is a destabilising factor across London or wider.
Denis Onyango (Lambeth Healthwatch, England): I just want to make a comment with
regard to the strategies. What is happening is that the public or the patients within the
community are finding it quite challenging understanding what is really going on We find
that, for example, southeast London clinical commissioning groups (CCGs) are just
developing, consulting on a common strategy for the next five years. At the same time, each
and every one of those CCGs have their own strategies, and then you find that there is sort
of a mismatch in terms of what is being provided. For example Lambeth’s strategy for
sexual health is of in consultation right now and is closing at the end of the month; and the
public find it quite challenging that within this short period of transition there is so much
going on and we do not know where services lie.
Healthwatch Camden, for example, has had a lot of concern around getting contraception to
women from backgrounds where culture, religion, hinder access; and they are quite
concerned that it is not being given enough prominence in some of the strategies. I just
think that, much as we appreciate that there are a lot of challenges along the transition and
with the budget split, what we would like to see, as the end users of public health services,
which are quite excellent in many respects, is to ensure that the quality of services is not
lost. Healthwatch want to also ensure that we are fully involved in the consultation
processes because there are a lot of people without a voice out there; and if we understand
what is going on, then we could participate fully. I think that is very important.
Andrew Boff AM (Deputy Chair): I was going to say, boroughs have reported these high
cost fluctuations that they have as a result of taking over public health, and it is a challenge
to continue those services, is it not, those needed services?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): It is. The financial challenge, if we look at that first, then
yes, it is clear. But the financial challenge is across all public services and would have been
there anyway, even if services had remained commissioned by the NHS. The challenges of
rising demand have followed us from the NHS, the challenges of meeting these hard-toreach groups have followed us. Therefore, as I say, I am certainly not saying there are no
problems. I am simply saying that they were no different because of transition and I think
there was a lot of anxiety before sexual health moved to local authority responsibility, or
public health moved to local authority responsibility, that somehow that would be a
destabilising factor and I do not believe it has been. I think that we continue to try to
address the problems that we have.
Harriet Gill (Area Director, London and South East, Brook Advisory Service): I was
going to talk about the experience of the charity sector. Brook is one of many charities
working within sexual health in London and our experiences have been very positive. In
terms of the fact that public health within local authorities is much more concerned with
preventative and holistic approaches, so that it is not just about treating conditions but
about education and housing and welfare and much wider issues for young people, in our
instance. However, I would draw the Committee’s attention to a British Medical Journal
(BMJ) article called Raiding the Public Health Budget, which was published a few months ago,
and based on Freedom of Information requests they made to local authorities, that many
services have had to be decommissioned because pressures on the public health budget are so
huge that budget money is being used to move away from sexual health and support other
essential public health expenditure. Nevertheless that has resulted in closure of services.
One of the things we could do in London, or perhaps lobby NHS England, is to think about
how local authorities, CCGs, the whole health economy, can work in a more joined-up way,
given that there was some separation, and that those authorities have a responsibility to
measure what they have been mandated to measure. Therefore the public health outcomes
framework sets out a whole list of sexual health related outcomes, such as reducing teenage
conception, Chlamydia diagnoses, late HIV, sexual violence, and others. How do we know?
We need to know how each of our boroughs is doing. Out of this article and a report of the
advisory group on contraception, Sex, Lives and Commissioning, it has only just come out,
that there is a lot of evidence that local authorities and CCGs are not reporting. They are
not carrying out needs assessments on their populations as much as they could. Therefore
services are being commissioned without a really thorough understanding of what is needed
locally and then, having established commissioning of services, we are not really monitoring
whether they are effective enough. I think that is partly just the transition and the huge
amount of work that is going on.
Therefore, in conclusion, it is a very positive thing for organisations to have moved into
local authorities and our experiences have been very positive within Brook; however there is
a real fear for the future, once public health budgets are no longer ring-fenced, and around
monitoring and assessing need on an ongoing basis.
Andrew Boff AM (Deputy Chair): I remember at the time when this concept was talked
about, especially with regard to the London-wide services the Terence Higgins Trust
provide; there was some wariness about whether or not you could continue to provide those
and that we might lose a London-wide perspective. What is your experience to date of the
reforms?
Daisy Ellis (Acting Director of Policy, Terence Higgins Trust): The transition has
resulted in certain changes, not only London-wide, but nationally, provided prevention
services and so on. There are no longer pots of money available for particular services such
as information support and so on. Therefore lots of those services have been funded through
other means, through our own charitable funds and so on.
I think there have been really positive changes. As we spoke about earlier, the opportunity
to co-ordinate services, including transport and housing, and making sure that they are
accessible, is fantastic. However, I think the local authorities need to get better and better at
identifying and really understanding absolutely what the needs of their local populations
are, so that those contracts, when they are put out, reflect what is needed. Because, as we
know, payment by results and block contracts result in people doing something to a
particular prescription and, unless we get that right, then we are missing the opportunity to
make sure that there is adequate outreach; that we are getting to the people that need those
services and encouraging them to go and get tested and treated. If that is not commissioned
from the outset then that makes it very difficult.
I think over the coming months, we have already had one big change from the Health Act.
We also have further changes coming through with the Immigration Act, which, while
sexual health services will absolutely remain free for everybody, and HIV treatment and so
on, the change in that approach and the mixed messaging that is going to come up, could
create yet further confusion. Therefore we have to make sure that those services remain
clearly accessible to Londoners and that they know where to go, because that confusion does
not take much for people to get bad information from different sources and to feel that they
cannot access those services. That outreach work into those hard-to-reach populations will
become even more important; to make sure that there is not a longer-term public health
impact.
Andrew Boff AM (Deputy Chair): I am a little concerned that we have heard now from
two separate sources that you are persuaded that local authorities are planning their public
health budgets with not a very good evidence base. Is that something that should alarm us
now, or should we give it a year to see whether or not that is the case? That is the
impression I am getting.
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): Paul [Dr Crook] is not here to comment. I think we also
need to be mindful that the evidence base does not always answer the questions that we
have. Therefore I would truly like to know why it is that I have a very high late diagnosis
rate in Kingston statistically; however, my absolute numbers of people with HIV are so
small that I cannot get drilled-down information. I cannot get granular-level data, because it
runs the risk of identifying the patients that we are talking about, because the numbers that
we are talking about are not considered statistically significant. I am no analyst, I am not an
academic or clinician, I am a sort of good old contracts manager/commissioner.
I would love to be able to do what is needed to get that diagnosis rate down and in Kingston
we have taken every step at every trigger point that is recommended under national best
practice. We have HIV testing in primary care, we took part in HIV testing week, we have
pop-up testing centres for HIV, however we still have this ever-high late diagnosis rate.
Now, my question constantly is one asked by yourself, Andrew [Boff], earlier, which is, is it
just that, because we are testing more people, would I naturally expect to see a peak in the
number of diagnoses, therefore a peak in the number of late diagnoses, because many of
these people will have waited many years to be tested, simply because we are increasing the
number of tests. What I am told is that is absolutely the correlation in some areas, like
Chlamydia, but we do not know whether it is or not in HIV, and therefore we are all
grappling, myself included --Andrew Boff AM (Deputy Chair): Yes, basically you are saying it is difficult to make an
assessment on a moment in time, you have to take a trend and you have to look over a
period. Therefore that really answers my question, it is whether or not we should panic now
or have a look in a year and say, are we still not delivering.
Daisy Ellis (Acting Director of Policy, Terence Higgins Trust): Exactly, and I think it
is more that there is an opportunity to make sure that we have the best data possible over
time. It is a transition time, so, yes.
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): I think needs assessment, again I do take the point, but again
I do think it is area by area, so needs assessments have taken place. In the first year of
transition we have had a London-wide needs assessment on HIV prevention needs. This was
the trigger for the three-year programme, which did revise services that take place, although
the overall spending remains the same. It has decommissioned London-wide outreach
programmes, but it is increasing spending on London-wide campaign and key prevention
messages. I absolutely do take the point, however, I do not believe that all of this is a sort of
reaction by an unknowledgeable group of people or without needs assessment broadly. We
are one year in and I think you can only do so much in one year.
Denis Onyango (Lambeth Healthwatch, England): I think one of the things that has
been elusive is the development of a common evaluation framework for sexual health
services and in particular HIV; because for a long time you have had different local
authorities, so different commissioning groups, sort of relying on data that broadly has been
produced in America. We do not have a very comprehensive evaluation framework and I
think it is up to the commissioners of London to try to develop this message, just as you are
trying to develop the tariff, the common tariff for commissioning. I think there should be
some talk around developing a monitoring and evaluation framework because that has not
been there really.
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): I would not disagree, and again that is not a loss in
transition, never has London had a single - what some people might refer to as – score-card
for London that shows different elements of STIs, teenage conceptions, and measures those
on a real time basis. We do get analysis after the fact, a year or two after the fact, through
the likes of Public Health England; however London has not had that and perhaps that is
something that we should be looking at. I would take that point.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): I was going to
make the point that in 2008 I was looking at national Chlamydia screening programme
testing sites in London. The areas that had fewer testing sites were the areas with more
deprivation in the south and the southeast in particular, and it was illuminating that we
were not testing the areas where we know we have a higher STI burden. Therefore there is
a discord between where services are. However, in 2011, Guy’s and St Thomas’ Charity
gave a grant to the social enterprise of putting together SXT to try to map services, because
I continually meet patients who say, “I had my implant put in at my GP, but they no longer
do that service now”, and then they travel around a number of providers before they finally
find one. That patient journey, when it is complicated, sometimes never comes to fruition in
terms of testing or getting access to services. There are some time-sensitive services such as
post-exposure prophylaxis and emergency contraception that we should have real-time
information on and we should have a really good evidence base around where services are at
the weekend.
When Burrell Street opened, we were the first seven days a week service and we are still the
only seven day a week service 18 months later. Yet we know that most of our clients are of
working age, and they cannot take time off work, and they want to see us on the weekend or
after work or before work. That is a real challenge for commissioners, having that
conversation, which is difficult, with providers about how you configure services and
improve access.
The final project I have done with SXT is put Adtags (outside of some clinics to look at
turn-aways. We are not measuring turn-aways, however I know that there is a tag outside
of the Brook in Southwark and that is one of the biggest users of the Adtag technology; and
you can see people out of hours are touching on this to try to find services that are open.
There is a real need, an unmet need, that we are not measuring and I think we need to
actively measure that to understand where the unmet need is, so we can convert it to a met
need. There is capacity across London through pharmacies, GPs, third sector, and regular
clinics, and we need to make the most of it. I do not think we are. I do not think there is
enough evidence base, speaking to your question.
Andrew Boff AM (Deputy Chair): Public Health England has now announced an
extension to the ring-fenced budget for public health. Is that going to make the sexual
health budget that much more secure?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): The two do not necessarily correlate, therefore it is an
announcement, as you say, of the security of the ring-fenced grant to 2016. Obviously it is
for local authorities to determine the public health needs of their population and to spend
their grant accordingly. As someone whose only job is to commission sexual health services,
I hope it will correlate to continued elements of protection around the spending that we
have for sexual health. Ultimately, the end of the financial year 2015/16 will arrive pretty
quickly and what we do not know is whether or not we will have a ring-fenced grant beyond
that or indeed what the settlement for spending on public health will be in that year and
beyond; although we know it will be ring-fenced we do not know yet the settlement for the
next financial year. Therefore, we have already mentioned a few times the financial
challenge that we have, and we will have to see where that takes us really.
Andrew Boff AM (Deputy Chair): Ok, thank you very much.
Dr Onkar Sahota AM (Chair): We talked about the importance of education, of screening
services, of commissioning services, however my concern is now I see there may be a lot of
breaks in all this; that we do not have a proper co-ordinated commissioning of sexual health
services right across London. Is that an issue? How will the 32 boroughs, relate to each
other and also the massive question that somehow the messages of public health are not
reaching the public. However, it is not just about a curriculum in schools, it is just that
people are not choosing to either use protective barriers or they cannot access them
properly. There are some issues, which makes me think that they may lack strategic coordination right across London. Would I be wrong in thinking that or will I be right
thinking that?
Peter Taylor (Sexual Health Strategic Commissioning Coordinator, Association of
Directors of Public Health): I have no wish to get into comparing against other services,
however, what I would say is you will not find a better networked, better co-ordinated area
of care than sexual health, both nationally and in London. I have been a commissioner for
sexual health services around the country for a number of years and wherever I have been
there has always been an England network of sexual health commissioners that get together
three times a year; and I have travelled the length and breadth to attend that and that
continues. As I say, in London what we now have, which, although we had the London
Programme before transitioning we did not have, a strict network of commissioners in
London; we now do and we meet every quarter. What we also have in London now is a
London Sexual Health Board, which is in effect a strategic body, which is chaired by
Mike Cook [Chief Executive, the London Borough of Camden]. It has representatives from
the provider side, so it has representatives from the British Association of Sexual Health and
HIV (BASHH), it has a representative from the faculty of Sexual and Reproductive Health, a
representative from NHS England and Public Health England. We have two lead directors
of public health for sexual health. You named the original two in your reporting, in fact
Mary Black is no longer one of the leads, she is no longer a director of public health in
London, it is now Penny Bevan who is the Director of Public Health at Hackney and the
City, and Jonathan Hildebrand, who you named, who is the Director of Public Health in
Kingston. Therefore there is plenty of structure and co-ordination and networking that has
come up in 12 months and from my point of view I think that has worked pretty smartly and
the network of commissioners, for example, met within the first few months and has now
met four times and our fifth meeting is in July.
In terms of that then working its way through to doing things together, again, that has
begun. The London-wide HIV prevention programme, funds secured for three years, there
are other consortia, which are clusters of boroughs that are doing things together, primarily
around HIV prevention and services for people living with HIV, but there are other
examples.
Boroughs in north London have formed an alliance around their procurement of GUM
services with 16 providers represented across that alliance of 12 local authorities north of
the river. Again, in the first year, a number of programmes have begun around
collaboration, collaborating to refresh the work on the tariff and all the boroughs in London
have signed up to running a London-wide Patient Group Directions (PGD) programme.
PGDs are directives that allow sexual health nurses and pharmacists to dispense medication
without the sign-off of a doctor under strict protocols, used across healthcare services. We
have 20 of those already established in London and they are available to the whole of
London to put in place. We are developing three new ones at least in this coming calendar
year. Therefore I really do feel that plenty has started. More to be done, but plenty has got
underway.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): There is lots of
innovation in sexual health. Ten years ago sexual health was the first service to start
providing results by text message; that was some work I did with Chelsea and Westminster
with [Dr] Ann Sullivan [Consultant Physician in HIV and Genito-urinary Medicine at the
Chelsea and Westminster Hospital]. We continue to innovate using computer-assisted
structured interviews, for example, and I am involved with [Dr] Gillian Holdsworth
[consultant in Public Health], and others, on a Sexual Health 24 project, which has just got
funding from Guy’s and St Thomas’ Charity to try to move into the virtual services so that
people can test using the virtual services online; however that works very closely with
stakeholders to make sure that we can manage positive results really effectively. There is a
lot of innovation in sexual health and we understand the pressures that commissioners have
around funding; and what we are doing within that programme is really assessing the
economic impact of moving some patients from clinic into virtual testing and making sure
that there is quality information about local providers within that. It is not just a disruptive
innovation, but it is one that works really well with providers. Therefore, in sexual health,
not only are we networked as has been described, but we are always trying to use new
technologies to communicate more effectively with the patients that would use our services;
however we obviously need to continue doing that.
Andrew Boff AM (Deputy Chair): Can I just ask, one thing that has not been mentioned,
and I am quite surprised we have not mentioned it so far, perhaps I missed it, is the sexual
health services to sex workers; and whether or not we have seen any changes recently with
regard to that or whether or not we are content we are getting to sex workers with regard
to information?
Daisy Ellis (Acting Director of Policy, Terence Higgins Trust): Terence Higgins Trust
runs a service called SWISH, which is Sex Workers into Sexual Health, which is one of
those services that is commissioned to reach out and engage with sex workers and make
sure that they feel confident to come to our clinic. We have one in Earls Court. Therefore
there is that safe secure environment and that they have appropriate routes into sexual
health services. I think one of the ways is that we need to make sure that there are a range
of services offered so that it is not simply engagement with regards to exiting sex work; but
that sex workers have options and, regardless of whether they intend to continue or stop or
change their life approach, that they have that route and access to sexual health services.
However, that clinic that we run and that service that we offer has been very successful and
it has also built up links between sex workers and the police to make sure that the police are
seen as a trusted partner, and that they can go to them with issues or problems that they see.
Quite often we see sex workers interacting and seeing early signs of criminal activity that
we can then liaise with the police and prevent further problems happening out in wider
public areas. However, I think there is always room for more services to be offered and for
more outreach to be taking place to make sure that everyone engaged in sex work, men and
women alike, are able to access those services.
Denis Onyango (Lambeth Healthwatch, England): Currently within the black and ethnic
minority communities, especially the African migrants, you find that there are a lot of people
or individuals who are engaged in commercial sex presenting for support; and we are
currently feeding back on the Lambeth, Southwark, Lewisham (LSL) Sexual Health Strategy
and we hope to highlight that very much. The only concern comes around the current
levels of knowledge with regard to these kind of communities, the refugees and asylum
seekers, because they are quite vulnerable; and they do not have really good knowledge
about the numbers of these individuals within these local authorities. I think that proper
emphasis should be placed on trying to commission services, to try and outreach areas where
most of these individuals are likely to be, to ensure that there are reached with services.
Therefore it is a very important issue that we see them every day and I want to make sure
that their needs are addressed. However, as it stands right now, there are quite minimal
services, especially for refugees and asylum seekers, which I think should be looked at.
Andrew Boff AM (Deputy Chair): The Mayor of Newham has said that he does not want
anything translated into any language apart from English. Is that going to present a
problem in getting the message over to asylum seekers?
Denis Onyango (Lambeth Healthwatch, England): I think it is quite practical that we
have resources in commonly spoken languages. Obviously you cannot practically expect
each and every language to have resources. I think, however, the most important aspect of it
is trying to have community volunteers or champions that do work with these communities
and are trained in understanding the English language; so that they can play an important
role, not only in translating or interpreting information, but also in trying to reach these
people to support them and motivate them to access services. Therefore I do agree with him
in part in that we should have information in English because that will also promote
integration.
Andrew Boff AM (Deputy Chair): Of course, it comes in English anyway.
Denis Onyango (Lambeth Healthwatch, England): I think we should not forget that
important aspect of trying to train volunteers and skilled community champions to be able
to reach these communities because it has helped us, especially in breaking down barriers,
with regards to HIV and FGM. I think it is an important aspect to look at.
Harriet Gill (Area Director, London and South East, Brook Advisory Service): Just to
add and build on Denis’ point really that we should also note the need for professionals to
respond to trafficked women on the whole and child sexual exploitation is a huge potential
and real issue for us in London and obviously elsewhere. As services and as commissioners
that is on the agenda every time we talk about meeting the needs of vulnerable young people
or any aged people; trafficked people and child sexual exploitation is an issue, because we
want people to come to services and tell us what is happening to them. However, it goes
back to Denis’ point to build that bridge between our services that are provided in a
building, reaching out to people who just do not have the history of accessing buildings for
advice.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): There is no
coding system that is within the integrated tariff for safeguarding issues. If you ask about
domestic violence, which we do for every person who comes through the doors in Guy’s and
St Thomas’ hospital and you identify there is domestic violence that creates obviously a level
of work. If you ask about child sexual exploitation and look at and identify safeguarding
issues within young people that generates a lot of work and that in itself does not attract a
tariff or does not attract funding, and yet it can end up being a lot of work. The danger is, if
you do not recognise that and support that type of work, then there is a danger that people
will not ask those questions and create that level of service
Andrew Boff AM (Deputy Chair): It is depressing though, is it not, the fact that at the
base of it all is money. Is the fact that we can miss identifying someone because he does not
come with a budget. The identification of that does not come with a sum of money and
therefore we can miss them.
Dr Anatole Menon-Johansson (Burrell Street Sexual Health Centre): You need to build
trust. Like in the case of Brook, you do not hear everything on the first visit, we build an
environment that allows young people to feel confident being in there, and then once that
level of trust is built up then you get disclosure. However, once you get disclosure, you need
to be able to support those individuals, and that does take time and it does cost money, of
course it does.
Dr Onkar Sahota AM (Chair): Thank you very much to all our guests for your
contributions this afternoon. We have certainly learned a lot and thank you very much for
taking the time and coming here. This will really feed into our deliberations and our
reflections on sexual health services across London.