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Enhancing Sexual Wellbeing in Scotland: A Sexual Health and Relationships Strategy: Proposal to the Scottish Executive

Implementing an integrated tiered approach

4.38 Following the appointment of the Lead Clinician, each NHS Board should develop a tiered service approach by integrating sexual health services across a range of disciplines and specialities (a detailed description is contained in the Supporting Paper 5A). In summary, this approach introduces a new model of integrated working based on five tiers ^t:

Diagram 1: Proposed Tiered Service Approach

• Tier One includes formal and informal sources of information and advice, which individuals may access directly. This can include NHS, Local Authority and voluntary sector staff, peers, magazines, leaflets and television.

• Tier Two covers services, which might not specifically focus on sexual health. For example generic drop in facilities, community groups, youth clubs and community pharmacies where people may obtain contraception and sexual health advice without the need to attend their doctor or a specialist sexual health service.

• Tier Three includes those services that respond to an individual's basic sexual health and reproductive health needs. These may be provided in primary care, community-based family planning clinics, specialist voluntary organisations (for example Caledonia Youth and other youth organisations, PHACE Scotland, fpa Scotland, Fertility Care Scotland), outreach GP and/or sexual health in drop-in services such as The Corner, Dundee and Sorted on Sex, Stirling. Services for target populations may also provide sexual health advice and care alongside their specialist service, for example drug prescribing clinics or homeless services.

• Tier Four covers many of the current services in specialist GUM and specialist family planning clinics. Primary care teams with a special interest in sexual health or local family planning and GUM clinics working in conjunction with primary care could equally provide services at this tier (as exemplified in part by the current GP personal medical services pilot in Stirling). In each Community Health Partnership (CHP) or locality, at least one service provider should be encouraged to attain the skills required to provide this service tier (thus being the identified CHP/locality sexual health lead).

• Tier Five combines the provision of specialist services such as HIV treatment and care, contraception and reproductive health, co-ordination of partner notification and elements of sexual and reproductive health needs assessment, psychosexual medicine, termination of pregnancy, clinical governance and quality assurance for all tiers.

4.39 This tiered approach builds on the wealth of knowledge and experience currently available within Scottish sexual and reproductive health practice. Further background on the issues to be addressed by sexual and reproductive health services generally, and the tiered service approach specifically can be found in Supporting Paper 5A. Some specific characteristics are listed in Box 6.

Box 6: Specific characteristics of the tiered service approach

4.40 The sensitivities inherent in many aspects of sexual health have led to a situation where GPs adopt a wide range of approaches and service delivery. Historically this has led to alternative and specialist service provision, which can be accessed directly by the public. Users and professionals alike place great value on the availability of this choice. As a result, a fundamental principle of this strategy is that every person should have a choice when accessing sexual health services and be able to self refer to all such services. The decision of individual practitioners to opt out of providing specific sexual health services is respected. In such circumstances, however, they must give information on, and refer patients to, accessible alternative services.

Recommendations

4.41 All services (whether generalist or specialist) should be provided by skilled, confident and suitably equipped staff who are able to respond to the needs of their user population, either directly or by referral to other service providers in accordance with clear protocols and guidelines.

Specific actions to reduce STIs

4.42 STIs, including HIV, affect people of all ages in Scotland. Incidence is greatest among those under 25 ^u but older men and women are also at risk, particularly those entering new relationships following the break-up of long term partnerships. These infections are an important source of reproductive ill health and place increasing demands on clinical services but can be prevented through the encouragement of safer sex practices. Many of the interventions aimed at reducing STIs also contribute to reducing unintended pregnancy. ^{113; 145; 150} To respond to this requires better information about trends, improvements in prevention, especially access to and use of condoms, early detection and prompt treatment.

Recommendation

4.43 Scottish respondents to the NATSAL 2000 survey ³ indicated that they used condoms as a barrier against pregnancy rather than as protection from STIs. Evidence also indicates that the use of condoms is reduced or almost non-existent in long-term relationships due to an assumption of mutual fidelity. ^21;103 The Reference Group was aware of the gender inequity in contraception provision between men and women (hormonal contraception is prescribed to women free of change). This might account in part for the low use of condoms as a preventive measure against STIs and unintended pregnancy. To address this, free condoms should be available for both men and women. Whilst the Reference Group recognises the likely resource implications associated with this, it recommends that the Scottish Executive explores the feasibility of making this a reality.

Recommendations

4.44 In England, health care practitioners are allowed to provide condoms to prisoners whilst being detained. This is currently not permitted in Scotland.

Recommendation

4.45 High chlamydia prevalence amongst young men and women is of particular concern. ^{v151; 152} Scotland wide data are limited for all age groups and better information is required to identify those at risk. The targets identified for increased testing will begin to respond to this ( see Boxes 8 and 9).

Recommendation

4.46 Immediate treatment of STIs in primary care is likely to improve STI control and patients with an STI are as likely as other patients to visit their GP. ¹⁵³ The Reference Group was made aware that patients receive STI treatment in GUM clinics free of charge, while prescription charges apply for those treated in general practice. This may be a barrier to individuals seeking treatment.

Recommendations

4.47 The report of the HIV Health Promotion Review Group ¹⁴⁶ remains relevant and if implemented would address both sexual health issues in general as well as those specific to people most at risk of HIV infection. The differing domestic and social needs of men and women with HIV should be recognised and supported by service delivery and referral routes.

Recommendation

4.48 Agencies for people with HIV could broaden their remit to incorporate other aspects of sexual health.

Recommendation

4.49 Recent increases in HIV prevalence, especially among heterosexuals and gay men, are of concern. ¹¹ To respond to this, efforts need to be made to minimise barriers to testing as well as ensuring that those at most risk from infection are tested.

Recommendations

For providers of clinical services, implementing this strategy will mean:

• Support for clinical quality and service improvements within a structured framework

• Multi-disciplinary and multi-agency partnerships on sexual and reproductive health issues

• Clear targets and standards for each element of service provision

• Increased partnership between all levels of sexual and reproductive health services in response to the needs of local population/locality served and ensuring an integrated approach to service provision and

• Being supported to acquire the necessary competencies to undertake practice

For users of clinical services, implementing this strategy will mean:

• Better information on services

• Having their needs met by appropriately trained and competent staff

• Improved access to quality services for treatment and support and

• Health promotion interventions appropriate to their sexual health needs

4.50 This strategy has already shown the clear links between sexual health and cultural and social determinants and the required actions (paragraphs 3.10 to 3.14). However, if STIs are to be combated, action also needs to be taken on other factors, which are associated with the spread of disease. These include poor and inequitable access to clinical services including contraception, high levels of asymptomatic or undiagnosed infection and ineffective partner notification measures.

Supporting access to services

Supporting access to services: Service configuration

4.51 The attitudes and outlook of the staff who deliver services are important for all age groups and especially young people, homeless people, BME communities and other vulnerable populations. ^{1; 2} For example, same sex GPs/nurses and nurse led services can positively influence the outcomes of interventions. ¹⁵⁴ Opening times, geographic locations, suitability of premises, and perception of the service by users may limit accessibility (for example, if men feel services are targeted at women or if women do not wish to see a male practitioner), ^1;2;4;5 These issues may also affect staff recruitment. ³⁶ Service providers should seek to identify and address barriers to access for their communities, actively involving users in this process. Promising examples include one-stop shops, generic drop in centres and integrated service provision, some involving co-location and others with clear integrated care pathways. ²

Recommendations

4.52 As well as improving access to services, the values and principles underpinning service provision is important as shown in Box 7. This should take account of the wider social and cultural determinants of sexual health. As a first step in implementing this strategy, sexual and reproductive health service provision should be assessed against these service values and principles and proposals to address any deficits should be identified in each inter-agency sexual health strategy.

Box 7: Clinical service values and principles

Recommendations

Supporting access to services: Developing professional roles to respond flexibly to the tiered service approach

4.53 Capacity and flexibility will need to expand to cope with the increasing demands on services resulting from rising STIs and other sexual health issues. Means to address this challenge are discussed in the remainder of this document. This includes the development of more flexible staffing responses within clinical services based on evidence-based practice. Local managed sexual health networks, protocol/guidelines and support for ongoing professional development will help make the best use of the appropriate sexual health staff.

4.54 GPs and practice nurses amongst other primary care providers such as local family planning clinics have an important role to play in the diagnosis and treatment of people with sexual ill-health as well as supporting positive sexual health promotion. Increasing the availability of sexual health services in primary care is a way of increasing access for those who are unable or prefer not to use GUM or family planning services. ¹⁵⁴ The Reference Group was mindful of the pressures currently faced by primary care providers. To achieve the balance of care provision across the proposed tiers, support through training and involvement in the managed sexual health networks will be key for primary care providers.

4.55 Within each Community Health Partnership (CHP), an identified sexual health lead will develop and support primary care and specialist sexual health provision and should be supported by appropriate resources to fulfil this role. Depending on local arrangements the lead may be a general practice, community based sexual and reproductive health service or voluntary sector organisation. This CHP lead will help develop sexual health knowledge, skills and expertise amongst CHP providers and draw on additional input from the specialist sexual health services as required, for example on issues such as partner notification.

4.56 The Reference Group recognised that the current level of payments made to GPs might not be sufficient to equip and encourage them to offer the improved and/or extended sexual health services necessary to meet this strategy's aspirations. The Scottish Executive Health Department should explore ways of addressing this, including through the General Medical Services contract.

4.57 The Reference Group noted that a well-defined career path for medical practitioners has been proposed by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Family Planning and Reproductive Health Care (FFPRHC). ¹⁵⁵ However, training positions have not received appropriate recognition or funding. The appropriate Post Graduate Medical Deans and NHS Education Scotland (NES) should address this. Status and career opportunities for non-consultant doctors, nurses and other health care staff working in sexual and reproductive health services also need to be further explored and supported through employers providing identified training places, mentoring opportunities and appropriate management frameworks.

4.58 Nurses working in primary care and in specialised sexual health services have made progress in developing their role through their existing contact with women to promote sexual health, targeting men's health as well as addressing the needs of at risk populations. For example:

• In a number of NHS Board areas, nurses supply or administer certain medications utilising patient group directions as well as providing specific training/support to other health care staff. There are also opportunities for nurses to undertake extended and supplementary nurse prescribing courses facilitating the supply and administration of hormonal methods of contraception

• In Tayside a community learning disability nurse offers a weekly well woman clinic in conjunction with family planning services for women with learning disabilities. In Glasgow, community learning disability nurses shadow specialist sexual health staff at the Sandyford Initiative so that they can provide a more effective response to the needs of their patients

• In Lothian, nursing staff working in Healthy Respect partnership projects are linking between primary care and specialist sexual health services

• In Argyll & Clyde, GUM services provide an outreach service to female prisoners

4.59 Building on the existing sexual health skills and effective practice of nurses at both specialist and primary care levels, the further development of nurse-led sexual health services and an enhanced career structure will address some of the capacity limitations likely to hinder the progress of the tiered service approach. This is subject to their current traditional duties being covered by others and the provision of appropriate training. As a first step, NHS Education for Scotland (NES) should assist in the development of competencies to support the sexual health nurse role in specialist and primary care services. These competencies will create a baseline for the Higher Education institutions to develop relevant accredited courses.

Recommendations

Supporting access to services: Rural areas

4.60 During the course of its deliberations, the Reference Group was made aware of the particular issues relating to the delivery of sexual health services in the rural context. Innovative approaches to deliver sexual health services should be explored: for example sexual health services could provide outreach clinics as part of The New Community Schools approach or telelinking between laboratory services and primary care could help the early diagnosis of infections and reduce how far people have to travel.

Recommendation

Supporting access to services: Information

4.61 There are many formal and informal sources of information about relationships and sexual health. These include NHS and non-NHS staff, peers, magazines, telephone helplines, the internet, leaflets and television. Individuals need accurate, unbiased information and services if they are to take responsibility for their own sexual wellbeing. Standardised, evidence based information on sexual health and services that is suitable for a range of audiences, including those not currently accessing services, should be provided through modern accessible methods of communication. Clear information and referral protocols should also be available to staff who will refer patients to services. This is important if the principle of having at least two routes to accessing services is to be achieved.

Recommendations

Supporting access to services: Confidentiality and anonymity

4.62 Feedback from the engagement process has suggested that most health service providers consider they provide confidential services, users do not share this view. ^{36, 118} Confidentiality is more complicated where services are provided simultaneously by health, education and social services due to differences in understanding of what confidentiality means for their practice. Actual or perceived lack of confidentiality is a major factor in preventing people (particularly young people and those living in rural areas) from accessing sexual health services. The balance between the needs of a person for a confidential sexual health service and the need to protect that person from sexual abuse and sexual exploitation is delicate, especially for those under 16 or those deemed to be vulnerable (for example people with learning disabilities). In all cases, the interests of the young person/child should take precedence over all other considerations. Service users, parents and carers and the general population should have access to clear and unambiguous information on what will and will not be disclosed by different agencies and professionals. Confidentiality needs to be looked at carefully and dealt with sensitively by everyone. Staff working with young people and other vulnerable groups need guidance to support them in their practice. The guidance being developed by the Healthy Respect partners for professionals and young people will be a useful framework on which to build national guidance for service providers throughout Scotland.

Recommendations

Supporting access to services: Anonymity of testing

4.63 There is no standard procedure for recording names when tests are being requested and evidence suggests that this prevents some people, particularly those who are at greatest risk, accessing services.

Recommendations

Supporting access to services: Contraception and termination

4.64 Women are more likely to use contraception consistently if they have chosen the method to suit their own circumstances. Everyone should have access to the full range of contraceptive methods. If a service provider is unable to offer a particular method, they must facilitate access to alternative readily accessible services. Since all methods of contraception are cost effective when compared to unintended pregnancy or STIs, ^21;103 access should not be restricted on grounds of cost. Referral between the tiers should promote access to specialist services where gynaecological side effects and complications or underlying medical conditions make use of contraception more complex.

4.65 To provide protection against STIs as well as unintended pregnancy, condoms should be available and their use encouraged, in addition to other forms of contraception. Promising practice should be supported. For example, early indications suggest that the availability of emergency contraception from pharmacies has helped to improve choice and access. ¹⁵⁶ When providing contraception, including condoms, staff should use the opportunity to promote positive sexual health.

Recommendation

4.66 Some unwanted pregnancies are inevitable and there needs to be supportive, consistent and appropriate methods of addressing this. Safe termination prevents unnecessary death and harm to women and is recognised by the World Health Organisation as a public health issue. ¹⁵⁷ The Reference Group was aware of the variations in service response and inconsistencies regarding gestation limits across Scotland and the restrictions placed on potential service expansion by legal requirements and recommends that this is addressed.

Recommendation

4.67 Health professionals may have ethical objections either to methods of contraception or termination of pregnancy. Whilst respecting this, these professionals have a duty to inform users of the services they provide and to clearly signpost/refer to alternative readily accessible services.

Recommendations

4.68 Comments made as part of the engagement exercise suggests that appropriate support may not always be provided to women, their partners and their families who have experienced termination, miscarriage or stillbirth. This is mainly due to a failure to recognise the unresolved emotional impact which can continue for many years. Relevant training and information to enable staff to recognise the signs and symptoms likely to cause long-term ill health should be provided.

Recommendation

Supporting access to services: Sexual dysfunction

4.69 Many individuals would benefit from support and intervention in relation to sexual problems. Feedback from the engagement exercise indicated that there are long waiting times to access specialist sexual dysfunction services and sometimes problems are unrecognised resulting in inappropriate service responses, for example the provision of drug therapies for erectile dysfunction will not address underlying psychological problems. People infected with HIV often encounter sexual dysfunction and associated psychological problems which may not be recognised by service providers. The needs of individuals requiring such psychosexual support could be helped by:

• Improving knowledge and awareness of psychosexual problems among primary care and non sexual health specialist providers

• Improving access to appropriate medication

• The development of appropriate protocols for treatment and referral within and across the tiers

• Increasing capacity through supporting staff in a broad range of more generic services linked to more specialist service provision

4.70 NHS Boards should review their current arrangements for prevention, treatment and referral for sexual dysfunction in relation to actual and potential need and where necessary develop local solutions or cross-boundary arrangements. These may be more appropriately located in community based settings rather than in formal clinic settings or developing capacity within primary care.

Recommendations

Reaching those in need of sexual health services

Reaching those in need of sexual health services: Partner notification and sexual health advisers

4.71 Contacting those whom a partner may have infected can reduce onward transmission dramatically. ^{158; 159} This can be achieved through partner notification but the practice varies throughout Scotland. Although partner notification is the primary remit of Sexual Health Advisers operating in GUM departments, in some areas family planning nurses take the lead. In other areas, practice nurses supported by named sexual health advisers undertake simple partner notification. Models adopted should reflect the needs of local populations as well as the capacity and competence of staff involved. This might require staff working across NHS Board areas particularly where there is no resident sexual health advisor or increasing the capacity of non-specialist sexual health staff with support from sexual health advisors.

Recommendation

Reaching those in need of sexual health services: Sexual assault

4.72 There are no multi-disciplinary, sexual assault and rape centres in Scotland, despite the numbers affected each year. ^w Indeed, there are no comprehensive services available within a healthcare setting. Collaborative partnerships between police, Procurators Fiscal, health and voluntary services can lead to improved personal outcomes, increased reporting and successful prosecution of sexual assault cases. ¹⁶⁰

Recommendation

Reaching those in need of sexual health services: Female genital mutilation (FGM)

4.73 FGM is illegal in the UK under the Prohibition of Female Circumcision Act (1985). ¹⁶¹ However it is still practised in some parts of the world. It is not known how many young girls in Scotland have undergone FGM or how many women have long-term health problems. ¹⁶² Further research to ascertain the picture in Scotland should be undertaken. In the short term, information on FGM should be disseminated to appropriate health, social care and education staff so that they can understand the specific health and physical outcomes for women, as well as the emotional and social impact of FGM. Parent education programmes should include FGM as an issue for consideration where this is relevant for the local population.

Recommendations

4.74 This section presented proposals for improving sexual wellbeing through lifelong learning and sexual health services. The next section sets out proposals to make this happen.

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