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Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy

An Integrated Tiered Service Approach

1. Introduction

1.1 This paper sets out the framework proposed by the Sexual Health and Relationships Strategy for the management and delivery of sexual and reproductive health services in Scotland. It also identifies some of the resource issues associated with implementing the tiered service approach. Supporting Papers 5B and 5C identify the issues which those services are seeking to address, and give pointers on the review level evidence and practice based evidence to support further practice and highlights the reasoning underpinning the proposed Strategy's recommendations in relation to clinical services .

1.2 Whilst this paper concentrates on clinical services, it is recognised that such service provision must complement the work undertaken to promote positive sexual health and lifelong learning about relationships and sexual health and to promote a more positive view of sexuality within Scotland.

2. Background

2.1 Sexual and reproductive health services are provided by a range of providers including general practice, community family planning, genitourinary medicine (GUM), gynaecology and the voluntary sector. In addition, other services such as Accident & Emergency Departments, services for homeless people and drug and alcohol services may also provide support for the sexual health needs of their users. Responding to sexual ill health and promoting positive sexual health is a challenge both in terms of the geography of Scotland and in relation to the needs of local populations. Nevertheless the key components of sexual and reproductive health services should address:

Diagram 1: The inter-relationships between the components of sexual & reproductive Health Services

2.2 There are many examples of good and innovative sexual health services across Scotland as demonstrated in the responses made as part of the proposed Strategy's engagement process. However, there are wide variations in terms of availability, quality and choice in relation to these services which may discourage or delay individuals seeking help and can result in late diagnosis and treatment of preventable sexual ill health problems. The Scott Porter review of sexual health services (Butler and Solomon 2002), and the engagement exercise undertaken as part of the Strategy's development identified a range of issues which impact on the provision of sexual and reproductive health services in Scotland. Hosie's analysis of European sexual health policy (Hosie 2002), Ingham and Patridge's review of policies in Australasia (Ingham and Partridge 2002) also highlighted similar issues which need to be addressed if improvements were to be made in terms of service uptake and unwanted pregnancy and sexually transmitted infections reduced.

Box 1: Challenges currently facing sexual and reproductive health services in Scotland

2.3 In addition, several respondents in the engagement process commented on the failure of clinical services to address the broader social and cultural determinants of sexual health and thus presenting a medical model of health.

3 Service principles

3.1 The Scott Porter review of services (Butler and Solomon 2002) and individual NHS Board sexual health strategies have identified a range of values and principles which should underpin sexual and reproductive health services. The proposed Sexual Health & Relationships Strategy identifies a core set of service values and principles which providers should use to assess their sexual and reproductive health service:

Box 2: Service Values and Principles

4 An Integrated Service Approach

4.1 To provide a more cohesive seamless approach to clinical services, the Sexual Health and Relationships Strategy proposes the development of an integrated tiered services approach in each NHS Board area. This is based on the managed clinical network model and the increased emphasis on local decision making and local clinical leadership (NHS Circular HDL (2002) 69, NHS HDL (2003) 11). This approach proposed a model of integrated working based on five tiers:

Diagram 2: An Integrated Service Approach

4.2 The following paragraphs explain further each of the Tiers for the provision of sexual and reproductive health services in each NHS Board area, together with examples of the different scenarios which might apply depending on local resources and developments. It is recognised that, for the smaller or Island Boards, Tiers 4 and 5 may have to be provided by a neighbouring service provider as part of a service Tier agreement.

4.3 The range of sexual and reproductive health services which should be available at each Tier is set out at the end of this paper. This does not mean to say that all providers should provide every element: it will be dependent on appropriate knowledge, skills and attitudes. Whilst practitioners will continue to have the opportunity to opt-out of providing services, clear referral protocols should be developed and made well known so that individuals can be referred/self refer to other providers.

Tier One: Self Management

4.4 Individuals obtain information about sexual health matters and service provision from a range of formal and informal sources including sexual health trained staff, peers, magazines, the Internet, leaflets or television. Feedback during the engagement process suggests that such information may not be easily obtained or be out of date. It is important that individuals have access to the necessary information and services to enable each person to take responsibility for their own well being. This includes the prevention of unintended pregnancy and sexually transmitted infections. Information on sexual health issues and services should be standardised and evidence based, use modern accessible methods of communication and incorporate messages/information for those not accessing services. Websites and CD Roms have proven useful for younger age groups: the Healthy Respect demonstration project in Lothian has employed a range of different methods to help get information across, for example bus adverts convey messages to all age groups and can help discussions among different age groups. Using Websites can provide information on service locations and opening times and can be used to target specific populations, such as gay men or lesbians. In Glasgow, the Steve Retson Project has used the Internet to get responses from users about the quality of services. Feedback from user organisations and from NHS Boards indicates that information on how to access services and the range of services providers is not as freely available either to users or to other health professionals. This can lead to non-use of services or late presentation/referral to services that are more appropriate and potentially unavoidable ill health.

Tier Two: Individualised Information with some intervention

4.5 People may choose to obtain contraception and sexual health advice without the need to attend their doctor or a specialist service. Community pharmacists are seen as a source of valuable information, particularly in view of their drive to have private consultation areas (The Right Medicine, 2002). They have proven effective in providing community based responses for specific target groups (for example, needle exchange/methadone maintenance programmes and emergency hormonal contraception). This provides an additional opportunity to address sexual health issues through the provision of free condoms. Pharmacy involvement in condom distribution schemes (sometimes known as C-card) has provided a second access option for young people to access free condoms, as demonstrated in Fife and Lanarkshire. This is to be encouraged and further developed in non-participating areas. A similar experience has been seen in the uptake of chlamydia postal testing kits currently being piloted by Healthy Respect in Lothian.

4.6 Public health nurses working in schools are ideally placed to provide young people with accurate and up-to-date information on sexual health services including details of where these services are, when they are open, how to book an appointment and what will happen during a visit (for example, through posters on notice boards, information in school welfare booklets, leaflets). Many already provide broader sexual health advice and information, for example on relationships, breast self examination, PMS. However, many are not confident about giving more detailed advice and support, although they perceive a need for it. (Craig 2002). The Framework for Nursing in Schools (Scottish Executive 2002) builds on the broader social role of school nurses in providing support and counselling to young people and provides a backdrop for further developing this role. (further examples on improving links between services and schools is given later)

4.7 The youth based service model identified in the Scott Porter review of services is an example of this Tier. Some are delivered in clinical settings, for example Fiz in Airdre and Teen Aid in Oban whilst others may be in a "youth project setting" as in Stonewall Youth. Sexual health services often form part of a more broader remit, that is youth training, wider health topics. All such services offer face to face delivery and may also provide a distance based services such as a website.

Tier Three: Baseline Services

4.8 There is a range of service providers who respond to an individual's basic sexual health and reproductive health needs. This includes GPs and other members of the primary health care team, specialist voluntary sector services (such as Caledonia Youth, Highland Sexual Health), community family planning clinics, outreach GP and/or family planning to generic drop in services with clinical outreach such as The Corner, Dundee and Sorted on Sex, Falkirk. Depending on the service required and the skills/competence of staff and resources, sexual health services may be provided on site or individuals referred onto more specialist services.

Tier Four: Enhanced Baseline Services

4.9 This Tier builds on the previous service provision. This could be via those general practices ¹ who have an interest in providing more specialist sexual and reproductive health services alongside other general medical services or through existing family planning services or outreach GUM services (or any combination of these) or other provider service. Some general practices have already explored this avenue either through Personal Medical Service pilots (as in Stirling) or from their own interest. To extend this to other areas, general practice staff will require support and training so that they can acquire the additional skills and knowledge to provide these enhanced services as well as providing a source of local advice and expertise to practitioners in the lower tiers. Primary care staff operating in Tier Three should be able to refer individuals to these enhanced services thus providing a more localised service response as well as having the continued option of referring to family planning, GUM (genito-urinary medicine) and other specialist services as at present - again individuals should also be able to refer themselves. Thus Tier Four services will have an educational/liaison role for good practice dissemination, liaison with specialist providers and local laboratories and a leadership role to champion change within their locality.

4.10 To provide a more localised specialist service, the proposed Sexual Health and Relationships Strategy recommends that in each Community Health Partnership or locality, at least one service provider should be encouraged to provide Tier Four services. This might be a general practice or could be a family planning clinic: where developed, they could act as the local sexual health lead providing support and facilitating development to other practitioners in their locality. Rogstad et al (2002) have developed standards for comprehensive sexual health services for young people. These provide a useful template for setting up and monitoring such services. This supplements the Best Practice Guidance on the Provision of effective contraception and advice services for young people issued by the Teenage Pregnancy Unit in England (2000).

Tier Five: Specialist Led Services

4.11 This combines elements of sexual and reproductive health needs assessment, facilitating clinical governance and quality assurance, co-ordination of surveillance and data collection for all Tiers as well as services such as specialist HIV treatment and care, contraception and reproductive health services, co-ordination of partner notification, psychosexual medicine, termination of pregnancy.

4.12 Currently, Tier Five services are accessed directly by self referral or via primary care, other specialist services, other health services and voluntary agencies. Self referral is important since these services provide anonymity and confidentiality which is highly prized by people who feel awkward or unhappy about consulting a health professional that they may know in another context. Sexual health issues are often highly sensitive and difficult to address. The further development of Tier Four services should enable Tier Five services providers to develop the specialist aspects of their practice more fully and provide a greater degree of support to locally provided services. The development of enhanced general practice services at Tier Four will also provide greater choice for patients at a local level.

4.13 Tier Five will continue to be the main organisers and providers of specialist training. However there should be greater scope for the placement of staff who are doing a more generic sexual health training in Tier Three/Four services. Tier Five will remain responsible for surveillance and data collection. They will also continue to be the experts in contact tracing and the management of complex conditions. They will hopefully be able to adopt a more integrated approach to care incorporating the service provision offered at Tier Four.

4.14 This tiered approach builds on the current wealth of knowledge and experience currently available within Scottish sexual and reproductive health practice. It is hoped that the proposed tiered service framework will promote a change of culture, which in time will allow service provision and contributions to be more evenly balanced across the tiers and ultimately will make it easier for patients to consult with practitioners in any tier about a range of sexual health topics.

4.15 Practitioners, particularly at Tiers Four and Five, should be able to develop the specialist aspects of their practice more fully and provide a greater degree of support to more locally provided services. In summary the tiered service approach should:

Some scenarios to help clarify roles of different tiers

5 Helping to Develop the Tiered Service Approach

Developing Professional Roles to Respond Flexibly to the Tiered Service Approach

5.1 Education and continuing professional development covering generalist and specialist competencies underpins the proposed Sexual Health and Relationships Strategy. Staff at all levels will need increased knowledge and skills to deliver the Strategy. This includes those working in a specialist sexual health post as well as those whose major role is not sexual health but whose practice might involve an element of sexual health whether that is in providing information, advice or direct services or in health, social care, education and the wider community. The need for staff at all levels to develop core skills in communication, attitudes and relationships in relation to sexual health is supported by the proposed Strategy as one means of addressing this.

5.2 In addition, the need for a clearly defined career structure in sexual and reproductive health care, the acquisition of competencies for each Tier and knowledge acquired at undergraduate level and ongoing professional development was recognised in the development of the proposed Sexual Health and Relationships Strategy.

Local Sexual Health Lead

5.3 Within each Community Health Partnership (CHP) or locality, an identified sexual health lead will develop and support primary care and specialist sexual health provision. 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 and the management of complex STIs.

5.4 It will be essential to those undertaking this locality lead role to have access to more specialist sexual and reproductive health practitioners (for example at Tier Four level). The range of supports suggested include:

• Access to mentoring/educational supervisor

• Direct access to specialist support

• Access to educational and relevant material, included protected time for CPD

• Access to health advisor

• Written confidentiality agreement for the service

• Access to medical and surgical termination of pregnancy providers

Some of these will also be applicable to Tier Four enhanced services operating in primary care.

General Practice

5.5 General practitioners, practice nurses and 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. 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. The Reference Group recognises that by no means will every GP and practice nurse wish or be able to change their practice substantially. Many may adopt modest changes if they assist their everyday practice. They are more likely to use high quality Tier Four services if they are locally available, comprehensive and clearly understood.

5.6 Primary care already utilises the concept of skill mix over a variety of settings using nurse led clinics and the extension of this is envisaged for sexual health services. However, the need for adequate numbers and training of GPs and other members of the primary care team both to ensure consistent quality of Tier Three care and adequate numbers providing Tier Four services is recognised by the proposed Strategy. The Strategy's Reference Group recognised that the new GMS contract provides a specific fee to encourage practices to offer the improved and/or extended sexual health services necessary to meet this Strategy's aspirations. Where these additional or enhanced services are purchased from general practitioners, they should be provided to defined standards (the proposed guidance to accompany the Strategy's implementation will assist commissioners in identifying these standards). In addition, a local audit of training needs of all providers with gaps being met through an identified training programme is a task set for each NHS Board area. The key will be to develop an approach that develop a public health perspective to sexual health utilising all members of the primary care team and ensuring an enhanced access to services.

5.7 It is recognised that during the course of their vocational training, general practitioners might not have undertaken any GUM or family planning practice over and above their obstetrics and gynaecology module. Indeed, feedback from the engagement exercise indicated that where this option already exists, there are suggestions for its removal. Instead of removing such an option, the new SHO training scheme should include an attachment to GUM and Community Family Planning services. Those GPs who wish to provide an enhanced Tier Four sexual health service should also undertake a similar attachment so that they can demonstrate their competency in providing services at this level: regular refresher periods should also be built into general practice standards for continuing professional development.

5.8 Research by Scade et al (Scade, Burns, and Graham 2002) identified that practice nurses are already carrying out aspects of sexual health care in a non specialist setting. Whilst giving out advice or information on a range of sexual health issues, many practice nurses report having had no formal qualification or training and whilst they may be interested in pursuing sexual health as a specialism, have many demands on their time and skills. (Craig, 2003). The proposed Sexual Health and Relationships Strategy will support the role of practice nurses through the development of local professional training programmes, ensuring general practice staff have access to up-to-date information on sexual health issues and knowledge of referral pathways to specialist sexual health services.

Specialist Sexual Health Medical Practitioners

5.9 The Reference Group noted that the Royal College of Obstetricians and Gynaecologists and the Faculty of Family Planning and Reproductive Health Care have proposed a well-defined career path for medical staff (RCOG, 2000). However, training positions have not received appropriate recognition or funding. The proposed Sexual Health and Relationships Strategy recommends that the appropriate Post Graduate Medical Deans and NHS Education Scotland should address this issue, for example through the provision of sufficient training rotations for specialist registrars and other medical practitioners. In addition, the status and career opportunities for non-consultant doctors, nurses and other health care staff working in sexual and reproductive health services need to be further explored and supported through employers providing identified training places, mentoring opportunities and appropriate management frameworks. The development of a sexual health network and professional training programme for practitioners working in all Tiers in each NHS Board as identified in the Strategy should help support this.

Nursing Staff

5.10 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. The engagement exercise highlighted a range of promising practice, some of which include:

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

• 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 so that they can provide a more effective response to the needs of their patients.

• The Glasgow Learning Disability Partnership includes nurses working alongside residential and day care staff to support the sexual health needs of people with learning disabilities and their carers. Work is underway to produce sexual health promotion leaflets for people with learning disabilities

• In Lothian, a number of nursing staff work in Healthy Respect projects linking between primary care and specialist sexual health services. A family planning community nurse in an inreach/outreach post teaches SRE sessions in schools and sign-post young people to a sexual health service provided by the same nurse. Another nurse works in Caledonia Youth focussing on increasing access to services for young people, particularly those who are vulnerable or have special needs. In GUM, nurses are facilitating the testing and availability of chlamydia testing with a particular emphasis on men.

• In Argyll & Clyde, GUM services provide an outreach service to female prisoners and in Forth Valley health care staff in Cornton Vale women's prison provide a well women service including sexual health advice and treatment

5.11 Currently most ' nurse led' services require medical support as the nurse relies on patient group directions (PGDs) for the supply of medicines. The establishment of independent and supplementary prescribing will help make 'nurse led' services more fully independent. This, will, however depend upon the formulary and how useful the items included are for the treatment of sexually transmitted infections. A combination of prescribing and PGDs could be an interim solution to this problem.

5.12 Extending the role of nurse can be developed through experience, advanced training and practice and the use of protocols and guidelines. This will mean considerable training and support for nurses to take on this new role. Nurses due to the nature of their training and grounded with a public health promoting role, work differently to their medical colleagues. In order to avoid a task-oriented approach to sexual health, nurses will be facilitated to deliver a clinical service using a holistic supportive approach towards current and potential service users. This may create a difficult tension since the balance of both quality and pace is critical to the provision of a safe and efficient service. However, some nurses already lead the provision of certain specialist services which are not primarily about the prescription of medicines. These may require expansion or development in Tier Four primary care services, for example, post abortion counselling, psychosexual counselling, menopause advice.

5.13 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. Feedback from previous staffing surveys (Scade et al 2002, Lamont 2003) supports such developments in sexual health nursing and the need to develop competency based standards and guidelines. In response to this and as a first step, the proposed Sexual Health and Relationships Strategy recommends that NHS Education for Scotland help develop 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.

5.14 The development of a career pathway for sexual health nurses will be necessary to enable nurses to respond to these competencies and the tiered service approach. It is recognised that some staff will wish to gain formal qualifications to support their practice whilst others may wish to gain recognition for their experience through a competency framework. The following suggests the range of examples associated with the proposed tiered approach:

• At Tier Two and below: the nurse should be registered on the First Part of the Register and have undertaken an accredited course of study which includes a general awareness of sexual health promotion and a knowledge of specialist services

• At Tier Three: nurses should hold an accredited nursing qualification in Family Planning/Genitourinary Nursing

• At Tier Four: In addition to Tier Three the nurse should hold or be working towards a specialist practitioner qualification in family planning or genitourinary nursing

• At Tier Five: in addition to Tier Four, the nurse should hold or be working towards a Masters in Sexual Health Nursing

5.15 This was strongly supported in an open consultation with nurses working in sexual health as part of the Strategy's engagement exercise. The guidance for nursing staff developed by the Royal College of Nursing in response to the Sexual Health and HIV Strategy (RCN, 2001) would be a valuable resource in developing this further.

Clinical Governance

5.16 Whilst the Lead Clinician is charged with responsibility for overall clinical governance for all Tiers, individual practitioners have a responsibility for ensuring that their service meets appropriate standards and practice. An example of how clinical governance could be supported at local levels is appended.

Clinical standards

5.17 The integrated tiered service approach and the managed sexual health network require shared standards of care between all providers and all service levels. Clinical service standards should ensure consistency of approach by all staff involved in sexual health services. A number of evidence based speciality standards have been developed for specialist practitioners (BASHH, Royal College of Physicians, RCOG, FFPRHC). The Scottish Intercollegiate Guideline Network (SIGN) have developed a guideline on the management of genital chlamydia infection (SIGN 42) and the Society of Health Advisers have recently developed guidelines for partner notification. Additional standards in development include generic sexual health standards for Community Health Partnerships and practice standards for school nurses and other community based nursing staff

5.18 It is recognised that, without effective "policing", implementation of these guidelines and standards may not be pursued with any uniformity and consistency which in turn affects service responses and user experiences. This may be due to lack of knowledge of their existence or the absence of implementation obligation or the fact that there are so many guidelines in so many areas. In addition there are no standards which cut across the whole of the patient's sexual and reproductive health care journey and regardless of point of entry. The Scottish Infection Standards and Strategy Group (SISS) have developed standards for the detection and management of STIs which should help develop standardised practice in this area. Views on the value of formulating national sexual and reproductive health standards will be sought as part of the consultation on the proposed strategy.

6. Conclusion

This paper briefly sets out the clinical framework which underpins many of the recommendations laid out in the proposed Sexual Health and Relationships Strategy. This will be supported by the wider sexual health network detailed in Supporting Paper 6. Further implementation guidance will be developed following the wider consultation on the Strategy's proposals

September 2003

Clinical Governance Framework for Sexual and Reproductive Health Services

The figure illustrates a possible clinical governance model for sexual services.

Clinical Services

Support Services

Clinical Service Framework
NOTES:

Quadrant 1: The rationale of the framework is that health professionals and their employers will need to ensure that they are able to provide a range of services/tasks outlined in this quadrant. The tasks described are for a "generic" professional providing a sexual health service, the balance of which will depend on the nature of the service and the health needs of the clients seen. The framework can be redrawn to consider individual aspects of professional activity in more detail. Clearly, appropriate training and qualifications are mandatory. Employers and their employees have a dual responsibility to ensure that they are appropriately qualified to undertake the tasks expected of them and to remain up-to-date. Quality assurance in professional activity should be based on needs led, evidence based and consistent approaches. This is largely the responsibility of individual health professionals and teams. If shortfalls are identified these should be made known to managers. The quality assurance boxes in the figure suggests a range of dimensions that need to be considered to ensure high quality services are (and are seen to be) provided.

Quadrant 2: This identifies in broad terms the important linkages that health professionals need in order to undertake their clinical work, such linkages need to be recognised, promoted, developed and fostered by the different management tiers.

Quadrant 3: lists the organisational support that health professionals require when undertaking their clinical work. Responsibility to ensure adequate provision of this essential non-clinical support lies with their managers.

Quadrant 4: lists some of the national and local policy context in which sexual health services are operating. It also recognises community health needs as a backdrop for the service. Awareness should be a professional and a managerial responsibility.

Conclusions:

Effective contributions and support from health professionals will help deliver high quality sexual health services. The clinical governance framework outlined here indicates that in order for health professionals to undertake clinical tasks safely and effectively, they are dependent on the active support of other professionals and agencies. Efficiency in sexual health services will require staff to have appropriate caseloads/workloads, the use of evidence based protocols, regular intra and inter professional links and meetings, sufficient opportunities for continuing professional development and audit, and having adequate administrative infrastructure.

NHS Boards providing these services should be able to demonstrate how such features will be recognised, safeguarded, developed and managed. When NHS Boards and the new Community Health Partnerships develop their inter agency sexual health strategies, they seek appropriate professional advice and support.

Adapted from the Implementation Guidance for the Sexual Health and HIV Strategy produced by Department of Health, London

References

Butler R, Solomon A. Review of sexual health services for young people in Scotland (Scott Porter). Edinburgh: Health Education Board for Scotland, 2002 www.healthscotland.com
Craig A (2002). School Nurse Sexual Health Survey. (personal communication)
Craig A (2003). The training needs of practice nurses in Lothian. (personal communication)
Hosie A. Sexual health policy analysis in selected European countries. HEBS, Edinburgh, 2002. www.healthscotland.com
Ingham R, Partridge. A review of sexual health policies and trends in the USA, Australia and New Zealand. Edinburgh, Health Education Board for Scotland, 2002
www.healthscotland.com
Lamont M (2003). Family Planning Nurses survey (personal communication)
Rogstad KE, Ahmed-Jushuf IH, Robinson AJ. Standards for comprehensive sexual health services for young people under 25 years. International Journal of STD and AIDS 2002; 13: 420-424
Royal College of Nursing. RCN Sexual Health Strategy: guidance for nursing staff. London, RCN, 2001
Royal College of Obstetricians and Gynaecologists. A blueprint for the future. A working party report on the future structure of the medical workforce and service delivery in obstetrics and gynaecology. London, RCOG, 2000
Scade C, Burns A, Graham N. A National Survey to Assess the Need for Further Education and Guidelines on Genitourinary medicine for GU nurses, practice nurses and family planning nurses.
Scottish Executive Health Department. NHS Circular HDL (2002) 69 Promoting the Development of Managed Clinical Networks in NHSScotland. Edinburgh, Scottish Executive, 2002.
Scottish Executive. The Right Medicine: a review of pharmaceutical public health. Edinburgh, The Stationery Office, 2002
Scottish Executive. A Scottish Framework for Nursing in Schools. Edinburgh, The Stationery Office, 2002
Scottish Executive Health Department. NHS HDL (2003) 11 A Framework for reform: devolved decision making - moves towards single system working. Edinburgh, Scottish Executive, 2003.
Scottish Infection Standards and Strategy Group. Draft Standards (personal communication)
Scottish Intercollegiate Guidelines Network Guideline No 42. The Management of Genital Chlamydia Trachomatis Infection. Edinburgh, SIGN, 2000
Teenage Pregnancy Unit. Best Practice Guidance on the Provision of effective contraception and advice services for young people. London, Department of Health, 2000 ( www.teenagepregnancyunit.gov.uk)

Websites:
Royal College of Obstetricians and Gynaecologists: www.rcog.org.uk
MSSVD: www.mssvd.org.uk ) now joined together to become BASHH:
Association of GUM clinicians ) British Association for Sexual Health and HIV
www.bashh.org.uk
Royal College of Physicians (RCP): www.rcplondon.ac.uk/www. rcpe.ac.uk/www.rcpsglasg.ac.uk
Faculty of Family Planning and Reproductive Health Care (FFPRHC): www.ffprhc.org.uk

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