SLH0019
Written evidence from Mr Jonathan Orr-Ewing
From Jonathan Orr-Ewing in a personal capacity.
A) I have been a Volunteer HIV/GUM with the Chelsea and Westminster Hospital NHS Foundation Trust since January 2018.
I work in Reception 8 hours a week at the sexual health clinics Dean Street Express and occasionally at 56 Dean Street, Soho, London.
I submit this evidence because I am extremely alarmed by the cuts in local government spending in the funding and therefore provision of sexual health clinics.
Preamble: since 2013 Sexual Health has been in the domain of local government. Local government budgets have been cut drastically and in London six sexual health clinics have closed in the last year. This has meant that the two clinics in Dean Street (Dean Street Express and 56 Dean Street) are facing a dramatic increase in demand while further cuts in the provision of our service are happening.
These two clinics are the gold standard in sexual health accessibility, innovation, diagnosis and treatment. Public health officials from all over the world come to learn best practice from these clinics.
Question for the Committee: When will the provision of sexual health services be returned to the NHS from the hands of local government?
This is the case with HIV/AIDS and hepatitis. Adequate provision can then be made. If provision is left with local authorities a serious public health issue will arise. 50% of local authorities have said they will cut this service following recent publication of DOH statistics. These show a worrying increases in syphilis up 20% over 2017, 78% increase in syphilis in MSM (men who have sex with men) and a 22% increase in gonorrhea since 2016.
Jeremy Hunt and Matt Hancock have both stressed the importance of embracing the need for change in the NHS in its culture, its technology (see 6), innovation (see 7), spreading best practice (see 8) early treatment and centres of excellence eg stroke care centres at various hospitals (see 9) and investment for the future (see 10).
1 Dean Street Express (DSE) and 56 Dean Street tick every box in this list and yet they face further deep cuts in funding. Currently these clinics see 12,000 people a month and the demand is rising fast because six other clinics have closed in London in the last year, yet with a rapidly rising need for extra service the provision is being cut. This will lead to a dramatic rise in STIs, as night follows day, and a serious public health crisis will follow.
3 HIV cases diagnosed at Dean Street have fallen from 75 a month a year ago to 16 thanks to its accessibility and innovations. With the current cuts in local government budgets the incidence of HIV/AIDS is bound to rise.
4 DSE operates an online booking service for people who want to have a sexual health check up. There are now only 70 appointments for this per day with 1,200 people trying to book them!
This week I personally turned away six distressed people who couldn't book online and who turned up at DSE begging for a sexual health check. There were three of us (two medical professionals and me) on duty at reception so that's about 20 turned away... two years ago DSE could offer a walk in service. The reduction of offer has been dramatic.
5 DSE alone sees over 300 patients a day with 230 being in high risk categories: MSM, sex workers, the young and, often worryingly, ignorant who have the ability to get very rapid diagnosis and treatment.
6 Technology: clients arrive, are greeted and then complete a computer screen questionnaire. Urine tests and swabs etc are handed out by reception and the client sees a medical practitioner for consultation and possible blood tests. The resulting samples are checked by the world's leading diagnostic machine. The results are sent to the client via text by the machine within 7 hours! Treatment can be given within 24 hours. Compare this with other clinics. Typically these take a couple of weeks to perform the same function.
7 Innovation: "Clap clinics", VD, stigma, dingy basement clinics hidden out of sight in back streets. These were the norm.
The innovation of DSE looking bright, welcoming, club like, non-threatening and "cool" has led innovation in sexual health interest and take up, and draws in the most vulnerable clients: the 16 - 24 year olds.
It also draws in people of my generation who would have never thought of sexual health checks as a routine and sensible exercise, and I am 67!
8 Spreading best practice: Public Health practitioners visit Dean Street from all over the world to learn from and implement the gold standard. One flew in from Australia for a 24 hour visit and we are having to reduce the service provision. We should be expanding it throughout the country!
The NHS doesn't turn people away, unless it's the local authority that controls a service. THAT'S WHY the DOH has to take back sexual health provision.
9 Early treatment and Centres of excellence: DSE and 56 Dean are THE central and definitive clinics. They need more investment, more availability not less. The only 'walk in' service in Chelwest is 10 Hammersmith Broadway and that is no longer open on one of the busiest days, Saturday.
10 Investment: DOH research shows every £1 spent on sexual health saves £11 in the long term eg unwanted pregnancies, expensive long term treatment eg HIV/AIDS - that's £700 a month for each AIDS patient. Over 40 years that's about £300,000, and that is assuming the AIDS patient doesn't have any illness or condition that befall every one of us. The additional cost of more complicated treatment with drugs etc is compounded.
11 56 Dean is where the doctors are based. They offer a range of medical treatments and support. The beneficial impact of their extraordinary and innovative service cannot be overestated. Workshops on family planning, Trans issues, the frightening increase in Chemsex and its attendant drug addiction, along with counselling, outreach programmes where a health advisor and a nurse visit the local prostitutes to offer screening, care and support, are just a few of the exceptional and frankly amazing additional services Dean Street offers.
As you have realised I have touched only the very tip of the iceberg.
B) I wrote, at the personal suggestion of Jeremy Hunt with whom I raised these issues at a dinner in London in June, to the PPS James Cartlidge. The text was almost identical to my Preamble and Question.
On Mon, Jul 9, 2018 at 4:59 PM, CARTLIDGE, James <james.cartlidge.mp@parliament.uk> wrote:
Dear Jonathan,
Thank you for your emails and I am sorry for my delayed response. As you know, I had not actually received your first two emails as they were redirected into my junk folder. I have reviewed your emails and raised the points that you have made with the Department.
Firstly, thank you for the work that you have been doing as a volunteer. You are clearly very passionate about these important services.
I am pleased to say that over the current spending period, we are investing more than £16 billion to help local areas deliver public health services, including sexual health services, for their communities. Although good progress is being made – for example there was a 18% decline in new HIV diagnosis in 2016 compared to 2015 - we recognise that there are challenges.
Public Health England (PHE) published an action plan in August 2017 to address concerns identified in their Sexual health, reproductive health and HIV: a review of commissioning report. As part of the action plan, PHE are taking forward a range of activities aimed at strengthening commissioning including providing evidence and data to commissioners to support commissioning and the monitoring of outcomes and building capacity and capability in sexual and reproductive health commissioning.
In relation to sexual health services in London, as you will be aware Councils across London worked collaboratively to agree a new model for sexual health services. Earlier this year a new online (self-sampling) service began to be rolled out that will deliver improved resident access and experience. Clinic access is still open to all, but streamlined with those able to use the online service supported to do so.
Across London, clinics will be providing integrated sexual health services, bringing together services for infections and for contraception. This combination is popular with service users, especially young people and young adults, helps to meet both needs together and is efficient, helping to make better use of resources. The focus is on supporting long term, financially and clinically sustainable open access sexual health services across the capital, based on shared clinical standards and outcomes.
As you will know, we have recently announced a significant and far reaching increase in NHS funding that will look to improve services across the system.
Once again, thank you for taking the time to contact me about this important matter.
Regards,
James
James Cartlidge MP
Member of Parliament for South Suffolk
C) 17th July I replied to James Cartlidge’s email:
I should now like to reply to your email:
I am interested that the Department "is investing more than £16 billion to help local authorities deliver public health services, including sexual health services, for their communities". Unfortunately you do not say what this figure was last year or what it will be in the future, so while it is a vast sum it is meaningless without a comparison.
"a 18% decline in new diagnoses in 2016 compared to 2015" Please see my point 3 in my original email. "Diagnoses are down from 75 a month a year ago etc"
You "recognise there are challenges" . Yes indeed. I refer to the question I asked Mr Hunt in which I quoted the 20% rise in syphilis and 22% in gonorrhea and 78% increase in syphilis in MSM.
Since clinic services are being so seriously cut back how will you address these increases?
The PHE action plan may “seek to strengthen commissioning..and building capacity and capability in sexual and reproductive health commissioning”.
How can this be achieved by cuts in the provision of the service they "seek" to strengthen? It is the exact opposite of what is happening!
"Clinic access is still open to all, but streamlined with those able to use the online service supported to do so."
Ask your Civil Servant to try and book a sexual health screening at Dean Street Express or better you try.
You will be one of 1,200 people trying to get one of 70 appointments for the following day.
Streamlined and supported? No bottlenecked and abandoned.
"...will be aware Councils across London worked collaboratively to agree a new model for sexual health services" This has resulted in the closure of SIX major hub clinics. Is this "building capacity"? Destroying yes, building no.
"Earlier this year a new online (self-sampling) service began..that will deliver improved resident access and experience". I'm sorry but how can this possibly be described as "improved resident access" when access to Dean Street Express is so reduced? 70 appointments a day reduced from 340! See my original email.
How can it be an "improved experience" with such extremely poor access to informed medical advice, counselling, reassurance and very rapid diagnosis and treatment?
Would you have taken swabs as a young person in your parents' home? Assuming your mother had somehow ignored the parcel delivered to you.... "What's that dear????"
Dean Street was at the forefront of combining "services for infections and..contraception". How can the closure of six hub clinics and proposed cuts at the Dean Street clinics bring this together?
Indeed all routine family planning services across CHELWEST have been closed!
The ONLY clinic to conduct complex family planning planning services is Dean Street.
That is why I asked Mr Hunt when he would take the provision of sexual health clinics back into the NHS. Because the clinics are funded through Public Health and not the NHS it doesn't take Einstein to see that the choice confronting many councils is: do we close libraries or clinics? This is a choice that local authorities are quite unqualified to make and should never be put in this position.
You may recall that the Dean Street clinics did everything the NHS wanted. They modernised. They increased the number of hours they opened. They became patient friendly. They engaged with the community and integrated complex family planning. How will this continue?
Incidentally Wiltshire County Council will no longer pay for their citizens to come to Dean Street Express. I wonder if any of the seven Conservative Wiltshire MPs even know this?
How about the citizens of West and South Suffolk? Will your county council follow suit? I wonder how I, as a Volunteer Receptionist, will be able to implement this post code lottery? Ah. I have it: a sign on the door saying "No Moonrakers"..
The problem of increased STIs is already happening. It will not go away.
1 Will you take back the provision of sexual health services into the NHS (because sooner or later you will have to to deal with the inevitable huge increase in STIs including HIV/AIDS)?
and
2 When will you, Mr Hancock or a senior civil servant (how about the one that composed your reply?) come and see us in Dean Street?
I look forward to a considered and specific reply this time.
Kind regards.
Jonathan.
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D) Our ref: DE-1144603
Dear Mr Orr Ewing,
Thank you for your correspondence of 3 August to Matt Hancock about the commissioning of sexual health services. I have been asked to reply.
I appreciate your concerns.
Local authorities took over the commissioning of most sexual health services as part of their new public health responsibilities in 2013. This includes testing and treatment for sexually-transmitted infections, HIV testing and raising awareness. These are important public health issues and giving local authorities the responsibility for commissioning will help them co-ordinate with other local organisations to improve public health.
The commissioning of treatment for HIV is now the responsibility of NHS England, which commissions it as a specialised service as it is high-cost and low-volume. This allows NHS England to ensure that the most clinically appropriate treatment is commissioned and that the most cost-effective drugs can be procured.
Having different organisations that commission sexual health services should not mean that services provided at local level are fragmented or provided in different buildings or at different times and places. Ministers expect all commissioners to work together through local Health and Wellbeing Boards to design and provide high quality services for patients.
The Government has to make difficult decisions to ensure sustainable public finances, as ultimately this is what will enable us to continue investing in core public services. The 2015 Spending Review set an expectation that savings would be delivered in local government public health grant spending, but still made available £16billion of funding for local authorities in England over the five years to 2020.
In addition to the services commissioned by local authorities, the NHS continues to invest significant resources in interventions that prevent illness and improve the public’s health. These include world-leading national immunisation and screening programmes, with ring-fenced funding of more than £1.1billion allocated to these key programmes in 2017/18.
The Department will continue to work in partnership with local government to find ways of delivering improved health outcomes, with national action complementing local efforts. Public Health England provides support, focusing its efforts on providing tools and advice to local authorities in delivering high quality public health by acting upon best practice.
As the matters you have raised falls within the remit of the local authority, you may therefore wish to raise your concerns with City of Westminster council directly. The contact details are:
Westminster City Hall
64 Victoria Street
London
SW1E 6QP
Tel: 020 7641 6000
Website: www.westminster.gov.uk/contact
I am sorry I cannot be more helpful.
Yours sincerely,
Andrew Wilkins
Ministerial Correspondence and Public Enquiries
Department of Health and Social Care
E) MORE EVIDENCE:
1 The BMJ of November 2017. Article titled: "Sexual Health Services on the brink"
- The Government public health grant, from which sexual health services are funded, has been cut steadily since 2015. An unscheduled cut of 6% (£200million)
took place in 2015-16. This will amount to cuts of 9.6% by 2020-21.
- Visits to open access genitourinary clinics rose by a third from 1.6 million to 2.1 million between 2011 and 2015.
2 Article in the Guardian of 3/8/17 titled: "Government cuts leave sexual health services at tipping point"
- there has been a 25% increase in patients seeking sexual health provision over the past 5 years.
- there will be £531 million of funding cuts to Public Health budgets (10% of the total) by 2020-21.
- People attending clinics rose from 1.94 million in 2012 to 2.46 million in 2016. That's 25%.
- Cases of syphilis were up 12% in 2016 That is an increase of 5,920 cases over 2015. The highest number recorded since 1949.
B) Empiricism.
My colleagues tell me that sex workers - prostitutes in this case - earn what they did twenty years ago.
Thanks to the rapid diagnosis and immediate treatment to those fortunate enough to be our Dean Street clients they are saved from continuing to work while infected
as many have children, have expenses we can only imagine: high rents, pimps etc. Without their walk in access to our clinics.....
The increased use of crystal meth by gay men who practice 'Chem Sex' is not recognised by many of them as drug addiction. Many think it is recreational....
Our clinics address this and offer education, support and counselling.
This is not part of the strict remit of the Dean Street clinics but it is one example of many of how the innovative leadership and passionate care of these clinics
makes a real and tangible difference.