Enhancing Sexual Wellbeing in Scotland: A Sexual Health and Relationships Strategy: Proposal to the Scottish Executive
5 Supporting Change
5.1 Why is Scotland failing to respond to the sexual ill health currently affecting its population? As well as the issues raised earlier, there has been neither leadership on sexual health issues nor recognition of sexual health as a priority at national or level. What is needed is a framework which champions sexual wellbeing at all levels, ensures its high profile among the other competing resource demands and enables all sexual health partners to develop multi-layered responses that will make a difference.
Leadership & accountability
At national level
5.2 The Scottish Executive should appoint a National Sexual Health Programme Co-ordinator who will be supported by a Ministerially-led National Sexual Health Advisory Committee (with cross-sectoral, multi-agency membership including non government organisations and affected communities). x It will oversee the implementation of this strategy and ensure adherence to human rights and legal frameworks. Progress should be reported annually. A full review should be undertaken five years after the strategy's initial implementation to enable it to respond to emerging issues such as the sexual health needs of an ageing population, increasing ill health amongst those with links to those areas with high and increasing HIV prevalence and those facing the greatest barriers to good sexual health.
Recommendations
The Scottish Executive should appoint a National Sexual Health Programme Co-ordinator who should be based within the Scottish Executive The Scottish Executive should appoint a National Sexual Health Advisory Committee, chaired by a Scottish Executive Minister, to guide the implementation and ongoing development of the strategy The National Sexual Health Advisory Committee should publish an annual report on national progress of the strategy A five yearly review should be published by the National Sexual Health Advisory Committee
|
5.3 The lessons from Healthy Respect and its collaborative working with health, local authority and voluntary sector partners have informed and should continue to inform national and local policy and practice on what works in respect of sexual health services for young people. Among other outputs, phase 2 of the Healthy Respect project should provide further guidance on ways to help partnership working and effective interventions involving a wider range of stakeholders.
Recommendation
NHS Health Scotland, through the Sexual Health & Wellbeing Learning Network should disseminate evidence, commission research and develop resources to support the ongoing implementation of the strategy
|
5.4 Tracking the impact of this strategy on sexual health knowledge, attitudes and lifestyles as well as outcomes, will be essential. The International Report from the 1997/98 Health Behaviour in Schoolchildren (HBSC) survey provides valuable comparative sexual health data on young people in Scotland, the US and seven European countries (additional lifestyle and health data is available on 28 countries). 163 The findings from the 2001/2000 HSBC survey are soon to be published. These will provide information on young people's health in a social and developmental context, including the sexual health of 15 year olds in over 30 countries including Scotland. 164
5.5 There are two snapshot surveys which address sexual behaviour among the adult population (NATSAL and Health Education Population Survey (HEPS)). Neither explores detailed aspects of cultural and social attitudes or specific interventions, services or sexual orientation. Consideration should be given to expanding these and other surveys which will be able to provide information and feedback particularly on those most at risk of poor sexual health outcomes. This will of course link with the work to be undertaken on developing a mass communications strategy outlined in paragraphs 3.15 to 3.19.
Recommendation
The National Sexual Health Advisory Committee, in conjunction with key stakeholders, should develop proposals to enhance existing lifestyle surveys to provide feedback on the target groups identified in this strategy |
At NHS Board level
5.6 Whilst it is vital that an inclusive approach is taken at all levels, there has to be viable mechanism to ensure action is taken to implement this strategy: NHS Boards are deemed to be the most appropriate body to co-ordinate and lead local action, in partnership with key stakeholders.
5.7 To help drive local implementation, the Director of Public Health should:
Ensure that their local sexual health strategy (whether in existence or in development) reflects local need, evaluates current service provision, promotes user involvement and develops a phased approach to improving sexual health through enhanced service provision, lifelong learning and identified actions to influence more general values and attitudes to sexual health.
Appoint a Local Sexual Health Co-ordinator, supported by a local sexual health strategy group. This co-ordinator should manage the network of all relevant sexual health providers and activities that contribute to the implementation of these multi-agency strategies: this is what is meant by a managed sexual health network. y
Recommendations
Each Director of Public Health should ensure the inter-agency local sexual health strategy reflects the key components of the national strategy and that ongoing development and implementation is led by a multi-agency, multi-disciplinary strategy group which reflects their local population Each Director of Public Health should appoint a Local Sexual Health Co-ordinator to facilitate the implementation of an inter-agency sexual health strategy on a NHS Board-wide basis Each Sexual Health Co-ordinator should facilitate the development of a NHS Board-wide managed sexual health network which includes all relevant local organisations and service providers
|
5.8 Each NHS Board, in conjunction with their Community Planning partners, should determine the exact methods by which they will achieve the targets for the improvement of sexual health in their own area ( see paragraphs 5.10-5.15). Progress made and proposed investment should be set out in Local Health Plans and monitored through NHS Board Accountability Reviews and annual reports to the National Sexual Health Advisory Committee.
Recommendation
5.9 Given their responsibility for education and social care and the links between sexual health and the wider social and cultural environment, Local Authorities are key partners in implementing this strategy at local level. Progressing the sexual health agenda through each Local Authority should be the strategic responsibility of the appropriate Director.
z Joint Health Improvement Plans, as part of Community Planning, should monitor progress. Progress on implementation of the McCabe report should be reported through HMIE inspection and individual school reports: HMIE reports should be made available to the National Sexual Health Advisory Committee.
Recommendations
Each Local Authority should designate a strategic lead for sexual health Each Local Authority should ensure that Joint Health Improvement Plans detail partnership working to address specific sexual health issues and the wider determinants identified by this strategy
|
5.10 Working in partnership with the voluntary sector and community-based groups (including faith organisations) will be essential to implementing this strategy at national and local levels. Voluntary sector organisations have been, and are often, the "champion" for sexual health and promoting user involvement in shaping service provision. These experiences should be shared with statutory service providers. Voluntary Health Scotland could have a valuable role in informing the National Sexual Health Advisory Committee on the involvement of the voluntary sector in managed sexual health networks and local service development/provision.
At Community Health Partnership or locality level
5.11 This strategy promotes the delivery of services at the most local level possible. To achieve this, leadership and supporting infrastructure similar to that for national and NHS Board area will be required. This may be at Community Health Partnership level or at smaller locality level depending on the geography and population coverage required. Local clinical leadership could be undertaken by local family planning clinics, general practice or other providers. Local areas might wish to duplicate the networking functions similar to those at NHS Board level: public health practitioners, Local Authority health improvement officers, public health nurses and staff working in the sexual health field will be a useful means of supporting this local and regional networking. Resources, for both development and implementation, will be required to support these local arrangements.
Clinical standards
5.12 The integrated tiered service approach and the managed sexual health network require shared standards of care between all providers and all service levels. In addition to those identified for lifelong learning, clinical service standards should ensure consistency of approach by all staff involved in sexual health services. There are a number of professional standards and good practice statements which have been developed by professional organisations. In addition, the Reference Group was made aware of those for STIs developed by the Scottish Infection Standards and Strategy (SISS) Group. The value of formulating national sexual and reproductive health standards should be sought as part of the consultation on this strategy.
Clinical Service Targets for STIs
5.13 Interim clinical service targets to address STIs are detailed in Boxes 8 and 9: other clinical targets have been mentioned in section 4. The Reference Group acknowledged that those relating to chlamydia would help with the ongoing implementation of SIGN Guideline 42. 59 Achieving these targets will require additional laboratory resources. In addition, it should be recognised that increased testing will result in an increase in numbers recorded in the short term.
5.14 Detailed timings have not been identified for all of these targets as it is recognised that it will take time to develop the capacity to respond to these targets. Views on the appropriateness of timescales could be sought as part of the consultation.
Recommendations
NHS Boards, through the local managed sexual health networks, should ensure the local adoption of the interim national clinical service targets set to address STIs including HIV NHS Boards should support the role of Tiers Four and Five in providing a leadership role, and developing and implementing service standards across the tiered service approach through protected time/training resources NHS Boards should identify the impact on laboratory resources in meeting the clinical service targets. The Scottish Executive should consider proposals for additional laboratory resources that result from the Boards' reviews
|
Box 8: Interim national clinical service targets for chlamydia
Within 18 months of implementation of this strategy, NHS Boards should analyse their current chlamydia test levels and agree incremental increases for achievement in the following financial year Each NHS Board should increase chlamydia testing by 25% per year (from baseline year to five years hence) Increase testing by 50% in those groups identified with a prevalence of more than 10% (baseline year) Nucleic acid amplification test (NAAT) should be used for chlamydia detection in all laboratories NAAT should be used for the diagnosis of gonorrhoea at Tiers One, Two and Three All male symptomatic patients should be offered testing at Tier Three service level 90% of individuals diagnosed with chlamydia should be treated within four weeks of patient receipt of results 90% of patients with chlamydia should be interviewed by appropriately trained sexual health advisers or those supported and trained by sexual health advisors within 4 weeks of receipt of results 50% of all index patients with chlamydia must have at least one contact with a successful outcome aa
|
Box 9: Interim national clinical service targets for other diagnoses and treatment
90% of individuals diagnosed with gonorrhoea should be treated within 4 weeks of patient receipt of results All treatment providers should undertake and document contact tracing Those undertaking partner notification should be appropriately skilled and supported by agreed professional protocols 90% of patients with gonorrhoea should be interviewed by appropriately trained sexual health advisers or those supported and trained by sexual health advisors within four weeks of receipt of results 50% of all index patients must have at least one contact with a successful outcome Each NHS Board should increase HIV testing by 25% per year (baseline year to five years hence) among individuals who present at Tiers Four and Five with a new STI Annual syphilis serology should be offered to individuals who are HIV positive Patients with HIV status should have their own sexual health needs recognised and responded to (for example, through regular testing of non HIV related sexual health aspects) 90% of mothers should be offered antenatal HIV testing
|
5.15 The recent House of Commons Report on Sexual Health 20 recommended the extension of chlamydia screening in a range of settings bb and the management of people with HIV/AIDs to be undertaken at primary care level. Views on the appropriateness of setting such targets for Scotland should be sought as part of consultation on this strategy.
5.16 Proposals should be developed to monitor the qualitative aspects of clinical services in each NHS Board area.
Recommendation
Lead Clinicians should ensure targets for service accessibility, for example, local knowledge, acceptability and use of services, and involvement of patients in service redesign are developed. Improving gender sensitivity and gender competency is a key aspect of this responsibility
|
5.17 The Reference Group considered the target of accessing specialist sexual health services within 48 hours as recommended in England 9;20 but no clear view emerged on whether this would be appropriate for Scotland. Views should be sought as part of the consultation process.
Data Collection
5.18 The Reference Group was concerned about the current quality and range of national and local information on the uptake and provision of sexual and reproductive health services. It was noted that while much resource goes into detailed data collection in a limited range of services, STIs diagnosed in primary care and other clinical settings are not routinely recorded or collected and that Scottish data is not reported in a way that allows comparison with the rest of the UK. Timely, appropriate and comprehensive data collected in a consistent way at both national and local levels will be essential to monitor the achievement of the targets and standards set out in this strategy. The Information and Statistics Division (ISD) of the Common Services Agency, in conjunction with key stakeholders, should review current systems and develop a strategy which will be capable of responding to future service and monitoring requirements across the whole spectrum of sexual and reproductive health providers.
Recommendations
ISD should lead action to develop standardised data collection to support the development and monitoring of sexual and reproductive health services and to meet the quality assurance standards of the tiered service approach The National Sexual Health Advisory Committee should consider the proposals developed by ISD for potential adoption as a national data collection framework
|
5.19 In 2003, the Scottish Executive Health Department approved a strategy to develop the existing STI Surveillance Systems in Scotland. This should be implemented by ISD and SCIEH in association with relevant clinicians and microbiologists.
Recommendation
Staffing & other resources
5.20 Staffing and other resource levels have not been set out in detail in this strategy. This is deliberate as it is for individual NHS Boards, in conjunction with their Community Planning partners, to review their existing services, take account of staffing reviews and develop incremental implementation plans in response to the integrated lifelong learning and service framework and targets specified in this strategy.
5.21 If Scotland is to address the sexual ill health experienced by its population, additional resources will be required to enhance the capacity of clinical services and laboratory services. Developing the managed sexual health networks, providing lifelong learning interventions, ensuring staff acquire appropriate skills to meet and respond to agreed standards and providing premises that are fit for purpose will require additional resources.
Recommendations
The Scottish Executive should provide resources to NHS Boards to "pump prime" the initial implementation stages of this strategy NHS Health Scotland, through the Sexual Health & Wellbeing Learning Network and in conjunction with other key stakeholders, should develop implementation guidance, particularly in relation to the service tiered intervention approach, links between schools and services and information/data collection, so that these will be available as part of the implementation process of this strategy
|
5.22 The Reference Group welcomed the continued ring fencing of the HIV monies allocated to NHS Boards. The Scottish Executive should review the level of this funding to assess its appropriateness to respond to the increasing prevalence of HIV infections in Scotland.
Recommendation
5.23 Differences in terms and conditions between health service professionals working in the sexual health arena were highlighted during the engagement process (for example between nursing staff working in primary care and those working in GUM clinics). It is acknowledged that Agenda for Change 165 might address some of these and where not, the Scottish Executive should consult with relevant professional bodies in order to address these inequities.
Recommendation
Education & continuing professional development
5.24 Education and continuing professional development covering generic and specialist sexual health skills is key to the successful achievement of the short and long term goals of this strategy. Undergraduate and pre-registration training programmes for health, education and social care staff should include a focus on the social model of health and include aspects of sexual health which enable them to support sexual wellbeing. Staff at all levels and in all sectors will need increased knowledge and skills on sex and sexual relationships: this includes those whose remit is not solely sexual and reproductive health (for example, staffing working in Accident & Emergency, general medical departments, teaching staff, social care staff as well as parents and carers). Local sexual health strategies should include an inter-agency training needs audit and plans to address these. As a short term measure, NHS Boards' Health Promotion Departments, in conjunction with local providers and supported by NHS Health Scotland, should facilitate core skills training on communication, attitudes and relationships (highlighting cultural differences) on a multi-agency basis.
Recommendations
The National Sexual Health Programme Co-ordinator should co-ordinate the development of a national sexual health training strategy to provide generic and specialist skills in sexual and reproductive health Each Lead Clinician should undertake an audit of the training needs of health care practitioners to facilitate the implementation of the tiered service approach Each Local Sexual Health Co-ordinator should identify inter-agency sexual health training needs in response to all tiers and plans to address these should be identified in the inter-agency sexual health strategy NHS Boards should develop joint training for health and Local Authority personnel to develop core skills in communication, attitudes and relationships addressing the wider social and cultural determinants of sexual health
|
5.25 NHS Education for Scotland (NES) should consult with professional bodies and training providers regarding the further development of competencies (and training programmes) in sexual and reproductive health care, including those being developed for nursing staff. The potential for distance based learning materials and computer-based skills development should be explored for both undergraduate and postgraduate training.
Recommendations
NES should work with professional bodies and professional networks to develop a competency-based framework to support the tiered service approach NES should work with the education sector and appropriate professional organisations to develop/enhance supporting training programmes at undergraduate and post qualification levels
|
5.26 It is vital that all relevant professionals have the skills and confidence to play their part in improving sexual health. Feedback from the engagement exercise suggested that many do not consider that their current skills equip them to support people in sexual health and relationship issues. Providers of undergraduate and postgraduate training programmes for teachers, social workers and others whose work covers sexual health and wellbeing should ensure that their courses adequately prepare these professionals to fulfil this challenging role.
Recommendations
The Scottish Executive, in conjunction with the National Sexual Health Advisory Committee, should work with professional bodies, regulatory institutions and statutory and voluntary training providers to ensure that undergraduate, postgraduate and ongoing CPD programmes provide staff with the range of skills and knowledge to respond to the sexual health and wellbeing agenda
|
Developing an evidence base for future work
5.27 The Reference Group identified several areas where there was little or no evidence of effectiveness and appropriateness of interventions aimed at influencing the cultural and social determinants of sexual health, sexual health behaviours and sexual morbidity. Lack of evidence does not equate to ineffectiveness but rather indicates a need for further research. Supporting Paper 6 identifies potential areas for future work. The National Sexual Health Advisory Committee should help determine the evidence and research to be commissioned.
Recommendation