Scottish Government

EXECUTIVE SUMMARY

Introduction

1. The purpose of this work was to Review Caledonia Youth's contribution to promoting sexual health and wellbeing, in the context of 'Respect and Responsibility', and in relation to funding made available by the Scottish Government. The Review was undertaken by independent company The TASC Agency. The Review was commissioned to:

• Evaluate the effectiveness of Caledonia Youth in delivering its own key aims and objectives
• Examine the extent to which Caledonia Youth provision reflects what the current evidence recommends in relation to a multi-faceted approach to effective education, information and clinical services (including contraceptive services)
• Determine the effectiveness of Caledonia Youth interventions in terms of reach and impact on health outcomes on the target group
• Assess Caledonia Youth's short and long-term strategic planning process
• Assess Caledonia Youth's contribution to developing and delivering national sexual health policy, namely 'Respect and Responsibility'
• Identify key strengths which can be built upon and propose solutions to any weaknesses which need to be addressed
• Make recommendations on the future direction of Caledonia Youth

Methodology

2. The Review team met with Caledonia Youth staff and Board, with young people who access Caledonia Youth services, and with external professionals (external stakeholders) to gather views. Observation of Education and Clinical services was also undertaken.

3. In relation to developing the approach and the tools for the Review the team drew on the analysis undertaken by NHS Health Scotland ¹ and the extensive work undertaken by Douglas Kirby and team for The National Campaign to Prevent Teen and Unplanned Pregnancy in the United States ².

4. This emerging evidence suggests that strategies to address poor sexual health outcomes should have a multi-faceted approach which includes Education and Clinical/Counselling services. The characteristics these services should have are described and have helped the Review to reflect on those services provided by Caledonia Youth. In addition to descriptions of service strands, evidence also suggests that a multi-faceted approach should address the wider influences in young people's lives (such as social environment or self esteem); it should also explore the extent to which services address and impact on aspects of sexual health and wellbeing (such as sexual knowledge or behaviour); and whether services/programmes are engaging with specific populations vulnerable to poorer sexual health (such as young offenders or young people who have a learning disability/difficulty).

5. It was not the intention of the Review to suggest that Caledonia Youth's work must reflect all such aspects or characteristics but to use the evidence base as an aid to exploring and describing what is done, what views are held about this work, and as a source of guidance on what might be possible.

About the agency

6. Caledonia Youth is a Registered Scottish Charity (No: SCO 22614) and a Company Limited by Guarantee in Scotland (No: 150976).

7. Originally a provider of services with a focus on contraceptive services the agency has developed into a provider of clinical services, education, counselling and information and training targeting both young women and men under the age of 25, especially teenagers. The agency has a commitment to work with specific priority groups seen to be at risk of poorer sexual health outcomes.

8. The agency currently operates out of three regional Branches; in Lothian, Forth Valley and Grampian and has contractual arrangements with Health Boards and Local Authorities in these areas. Since 2006 the agency has also developed a new partnership with the Scottish Prisons Service, the initiative means the agency is working in three Young Offenders Institutions/Prisons.

9. The Scottish Executive/Government ³ has provided funding support to Caledonia Youth (formerly as Brook in Scotland) since 1992. Additional funds were made available for a 3 year period from 2001 to establish further branches however a lack of consultation about this development and a poor start to partnerships on the ground continues to impact on aspects of reporting, communication and trust.

Context: national sexual health policy

10. Caledonia Youth has been well placed, through its Chief Executive, to inform and engage with development of national policy and new NHS Quality Improvement Scotland standards. At a local level staff are well informed about national policy and share a commitment to improving sexual health outcomes for vulnerable populations.

11. The agency has expressed a concern about the focus to date on clinical services as the response to poor sexual health, however, the Government's response to the recent stock-take review on progress and implementation of 'Respect and Responsibility' ⁴ has now identified an approach to improving sexual health outcomes from 2008 to 2011 which offer new opportunities for Caledonia Youth including enhancing the role of the voluntary sector, making links between mental ill health, alcohol use and sexual health, a focus on improved evaluation and an interest in tackling the cultural and social context for sexual ill health. It would seem that this is an opportune time for the agency to consider how best to raise its profile and work in partnership with others.

Delivering on the agency aim

12. The stated aim of the agency is: "To make Caledonia Youth welcoming to all young people in Scotland, responding to their individual needs, upholding their rights and representing their interests. In doing so, we strive for confidentiality, openness, trust, dignity and empowerment in an environment that is approachable, non-judgemental and easily accessible".

13. The agency aim is well understood by staff, is reflected in agency policy and delivered operationally across services. External stakeholders also recognise the importance which the agency places on this aim, and agree it is understood and delivered effectively across services.

14. The contributions from young people support agency claims to be welcoming and focused on meeting individual needs in a service which is committed to building long-term relationships with young people. Confidentiality and trust underpin these relationships. The agency recognises the stigma which can be associated with sexual ill health and provides a non stigmatising service. Many of these characteristics of services have been observed in clinical and education practice.

Addressing wider influences

15. There was an understanding of the importance of wider influences in all strands of the agency's work. Caledonia Youth services are alert to these factors and take them into consideration across service provision. In particular the impact of poverty and poor self-esteem on choices, opportunities and behaviours was identified.

16. A further theme across contributors was the complexity of young people's lives, and the need for a sense of realism about what one service can achieve, whilst remaining positive about the need to do as much as can be done to address environment, behaviour and choices.

Addressing and impacting on aspects of sexual health and wellbeing

17. The review has drawn a distinction between what can be evidenced about how specific aspects of sexual health and wellbeing (such as knowledge, attitudes, behaviours, social or emotional aspects) are addressed and how claims can be made they are impacted upon. Caledonia Youth is confident that the agency addresses key aspects of sexual health and wellbeing. Across contributions it was agreed that understanding and evidencing impact is difficult.

18. Anecdotal evidence of impact was presented, sourced from relationships built with young people over time. There is also some quantitative data available although scepticism about its usefulness in tackling or understanding some of the more challenging aspects of social or cultural attitudes and behaviours which underpin poor sexual health. Concerns were expressed that national policy focuses on actions and not outcomes, and that opportunities to learn from emerging evidence from the evaluation of the national health demonstration project Healthy Respect should be created.

Engaging with specific populations

19. There was recognition of the skills, knowledge base and commitment of Caledonia Youth staff to populations with poorer sexual health outcomes. While many services are delivered through the agency's Branch structure the Young Offenders Project is identified as a new model of work which effectively targets a vulnerable population of young people.

20. The agency's work with young people with learning disabilities/difficulties is recognised as a particular strength and area for growth. There is a need for Caledonia Youth to build skills and knowledge in relation to this group and strengthen partnerships in order to improve access to services.

Reviewing education services

21. The agency's Education services, offered in a range of settings and in groups or one to one, reflect the characteristics identified as important by current evidence. In particular the agency delivers education work which is focused on using participatory approaches and experiential learning. Sessions are well planned and staff are flexible and responsive to what is presented in the course of a session. The challenges faced in addressing communication skills and building self efficacy are recognised, and opportunities for one-to-one work are seen as particularly valuable in addressing complex issues.

22. The agency is committed to providing inputs of adequate duration but there were some concerns about host agency commitments to providing coherent and adequate programmes. Better links with local partners delivering programmes such as SHARE are required. There is a need for the agency to address the extent to which education practice is informed by theoretical models and by current developments in relation to "A Curriculum for Excellence" ⁵ There is strong evidence that the services are delivered by motivated staff with a belief in the ethos and purpose of the agency. For some external stakeholders Education services were seen as a key area for agency development.

Reviewing clinical services

23. The agency's Clinical services work reflects the characteristics identified as important by current evidence. In particular the service is committed to client confidentiality, accessibility and to engaging with high risk groups.

24. Complexity and vulnerability is evident in consultations. Staff interviewees placed emphasis on agency ethos and building relationships with service users over time so that specific risk and protective factors can be addressed. There is strong evidence that the services are delivered by motivated staff with a belief in the ethos and purpose of the agency.

25. Agency strengths have been identified in terms of a commitment to, accessible opening times and a trusted service when it comes to discussing a range of issues from contraception to issues such as coercion and alcohol use. The agency has also evidenced its links with other agencies and referral pathways are established. In terms of partnership working the agency would benefit from improved communication with others about some aspects of policy and clinical practice.

Reviewing counselling services

26. Key strengths in counselling services were a commitment to confidentiality, clarity about the theoretical models used, and a focus on identifying risk and protective factors to be targeted. There is strong evidence that the services are delivered by motivated staff with a belief in the ethos and purpose of the agency.

27. There was support for Counselling services amongst external stakeholders who were actively engaged in referral. The strengths of the service were seen in terms of ease of access, a clear understanding and empathy with young people's needs and experiences, and the very fact that the service is rare. However, for more senior staff engaged in commissioning and review, there were several issues raised about the need for more information, improved reporting and better evidence of what the agency does, how and with what outcomes in relation to Counselling.

Reviewing information and training services

28. Caledonia Youth's information provision is delivered via a web site and series of information leaflets, with work currently underway to improve both sources. Training for other professionals is also provided. Both areas of work are considered by the agency to have potential for growth.

Strategic planning

29. The Review has identified positive aspects of the agency's capacity for and approach to planning as well as challenges which must be addressed. The agency has a strong staff and management team with a commitment to providing the best range of services which meet needs they well understand. A growing commitment to tackling health inequalities and addressing the needs of the most vulnerable young people does however bring into question current organisational structures for service delivery, internal capacity for growth and highlights funding dependency on NHS Boards and central Government. There is also the need to renew partnerships and improve reporting and evaluation.

30. In recent months the agency has been taking stock, recognising the direction of travel and considering the realities of what sustaining and growing services will require. Key draft documents looking at strategic planning and fundraising have been shared and discussed. The Review has identified that the agency must ensure that emerging strategic plans are less narrative and more clearly focused on actions and outcomes.

Overview of strengths and weaknesses

31. Agency strengths include a commitment to delivering on the agency vision, to engaging with vulnerable and marginalised young people, to delivering services which are bespoke, flexible, non-stigmatising. Within the agency there are commitments to good systems for staff support and supervision.

32. Areas which could be improved upon include funding vulnerability, improving some aspects of internal communication and pay, developing the Board and improving engagement with young people in service design and evaluation. Staff would like to extend clinical provision but recognise changes in the service landscape which must be considered.

33. There are also aspects of the agency which have both strengths and weaknesses. There is a need to improve reporting on and evaluating practice. Better approaches will come through joint work with commissioners and other providers. Secondly partnership working could be improved. Much has been achieved in building relationships with young people and some partner agencies. Improving other relationships is recognised as essential for the future.

Recommendations

34. Recommendations are located within refreshed national policy commitments to tackle health inequalities and improve sexual health outcomes.

Six recommends are made:

Recommendation 1. Rethinking the 'model': moving from a branch structure to a focus on service strands:

35. The agency needs to restructure and define itself as a provider of services rather than operating branches. These service strands should focus on delivery, change and innovation and would be organised as: Clinical Services; Counselling Services; Education Services; Information and Training Services.

Recommendation 2. Managing and resourcing this model:

36. The agency must rethink current management structures and capacity. National leads for each service strand should be appointed. A small core business team should be created which will bring a more integrated approach to communications, fundraising, evaluation and planning. The Board should be developed and extended; seeking members with specific skills and roles. The agency should be careful of unsustainable growth through project work. Ultimately a new model of service organisation and delivery will result in income generation and a more broad-based and secure funding position.

Recommendation 3. Finding the right niche and improving external relationships and partnerships:

37. The agency is moving toward service provision for those young people most vulnerable to poor sexual health and wellbeing. To develop this niche where branches are currently located means the purpose and focus of work contracted by NHS Boards needs to be re considered by those Boards and by Caledonia Youth working together with a renewed focus on improving outcomes; consequently some elements are likely to be renewed and some approaches and tasks are likely to change. Concerns about potential professional isolation or different practices must be addressed. In terms of new work the agency needs to commit itself to meaningful and broad-based consultation and relationship building.

Recommendation 4. Reporting on and evidencing impact:

38. Reporting on work is overly narrative, individualised and fragmented and evidencing impact is difficult. The agency must use emerging evidence and consider how it thinks about, reports on and evidences impact. It is recognised this is a challenge across all sexual health service providers and an area of learning and development which the agency should engage in with others.

Recommendation 5. Theoretical perspectives: The nature of Caledonia Youth's engagement with young people:

39. Without a clear foundation in theory it is much harder for Caledonia Youth to articulate the nature of their engagement with young people. This challenge is faced by other service providers too. It seems that providers are focused on what they do (actions) and what is expected or hoped for (outcomes). The Review recommends that the agency considers the emerging evidence about what works in the provision of services/programmes and also reflects on the theoretical base which should inform service development, design and delivery. Counselling staff already talk confidently about theoretical foundations. In Education and Clinical work staff would benefit from consideration about how their practice connects with the cognitive, emotional and environmental influences on learning for sexual health and wellbeing and behaviour change. Sharing discussion and learning about theory with colleagues from other agencies will benefit everyone working for better sexual health and wellbeing.

Recommendation 6. Specific service strands:

40. In terms of Clinical services it is recommended that the outreach clinic model is further explored and extended; whilst taking account of targets on waiting times and client numbers the focus should remain on quality and ethos; the agency must clarify with other providers how confidentiality, child protection and patient group directions on prescribing work; further work should be initiated on the links between poor sexual health and alcohol use.

41. In terms of Counselling services the agency must improve reporting; and explore how this service can meet the needs of increasingly vulnerable or marginalised young people.

42. In terms of Education work the agency must

• improve reporting;
• ensure that commissioning agencies understand the challenges in working with vulnerable young people;
• work more closely with colleagues where statutory Education teams operate to ensure services complement and support each other;
• ensure continued clarity about the interface between one-to-one education work and counselling;
• engage fully with "A Curriculum for Excellence".

43. In terms of Project-based work caution is required and the Review recommends all work should be located within a service strand to ensure integration and adequate support.

44. Finally, in terms of Information and Training current efforts to improve information provision should continue but a cautious approach to extending beyond current capacity should be adopted.