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Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy
Supporting Change
1. INTRODUCTION
1.1 This paper outlines the broader national and regional framework and leadership that will facilitate the development and ongoing implementation of the proposed Sexual Health and Relationships Strategy in Scotland. This framework is intended to support the delivery of clinical services, the enhancement of lifelong learning on sexual health and the promotion of a culture change towards positive sexual wellbeing in Scotland.
1.2 Throughout our discussions with NHS Boards, professional organisations and individuals with an interest in sexual and reproductive health matters, an explicit request was made for the proposed Strategy to be driven by clear strategic leadership from national level down to individual community level. In developing proposals, the Reference Group has supported the need for such 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.
2. Leadership & accountability
At Scottish Executive level
2.1 The proposed Sexual Health and Relationships Strategy highlights the impact of wider cultural and social factors on sexual health and wellbeing. It is therefore essential that national policies, which address issues such as social inclusion, incorporate actions to address sexual health. In addition, tackling stigma and discrimination arising from an individual's sexual orientation or sexuality requires national action: opportunities to explore this as part of the social inclusion agenda should be taken.
At national level
National Sexual Health Programme Co-ordinator and National Sexual Health Advisory Committee
2.2 The proposed Sexual Health and Relationships Strategy should be viewed as an early step in the ongoing development of the sexual health agenda in Scotland. In order to maintain the momentum engendered by the Strategy's development, the Reference Group recognised the need to establish a clear multi-department sexual health lead within the Scottish Executive and supported by a central mechanism to drive the implementation, monitoring and evaluation of the Strategy. To this end, the Strategy proposes that the Scottish Executive appoint a National Sexual Health Programme Co-ordinator who will be supported by a National Sexual Health Advisory Committee. An appropriate Scottish Executive Minister should chair this in order to maintain the national emphasis on the sexual health and wellbeing agenda.
2.3
Membership of this advisory committee should not only reflect health interests but all the potential stakeholders who have an interest in sexual health and wellbeing. The range of members should reflect the wider determinants of sexual health and the range of statutory and voluntary sector providers, but could include representatives from or specialists in public health and epidemiology, GUM and family planning medicine and nursing, primary care, Local Authorities, school based education, social inclusion, health promotion, voluntary sector, the HIV community, user and self help groups and research/academia.
2.4 The main
task of the advisory committee will be to oversee the initial implementation and ongoing development of the proposed strategy. As part of monitoring progress, annual reports are recommended together with a full review five years after the strategy's initial implementation. Given that it was recognised that the proposed Sexual Health and Relationships Strategy could not deal with the full breadth of sexual health agenda, this review should enable flexibility in national and local responses 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.
2.5 Key activities for the National Sexual Health Advisory Committee include:
Development of a mass communications strategy involving campaigns, advocacy and literacy
Commission of research to identify actions to maximise sexual wellbeing among those at greatest risk of ill health
Promotion of a consistent approach to school based sex and relationships education
Addressing the needs of rural areas
Facilitating a cross-departmental approach to sexual wellbeing
Healthy Respect National Demonstration Project
2.6 In undertaking its tasks, the Advisory Committee will be supported by the national demonstration project, Healthy Respect and the Sexual Health and Wellbeing Learning Network.
2.7 Healthy Respect is a partnership initiative bringing together 13 partners from health, four local authorities and the voluntary sector in Lothian. There are 19 projects working across a range of locations including schools, further education colleges, Caledonia Youth, Edinburgh Rape Crisis Centre and in hospital, primary care and informal youth settings. Activities focus on three main areas: teenage pregnancy, sexually transmitted infections, self-esteem and confidence among young people. As a national demonstration project, Healthy Respect acts as a "test bed" for new initiatives around sexual health: the lessons from phase one will inform national and local policy and practice on what works in respect of sexual health services for young people (anticipated being available in autumn 2004 - further details of Healthy Respect can be found at
www.healthy-respect.com).
The Sexual Health and Wellbeing Learning Network
2.8 Based in NHS Health Scotland, the Sexual Health and Wellbeing Learning Network will support the ongoing implementation of the proposed Sexual Health and Relationships strategy through an evidence into practice programme comprising evidence dissemination, commissioning of research and resource development and disseminating learning from the partnership activities of Healthy Respect project (further details of the Learning Network found on
www.phis.org.uk/projects/default.asp?p=fc)
2.9 Actions identified in the proposed Strategy for the Learning Network include:
Reviewing and disseminating evidence on the needs of those facing the greatest barriers to sexual wellbeing: in the first instance, focusing on people with learning disabilities and black and minority ethnic communities
Supporting the development of a consistent approach to sex and relationships education across the school curriculum
Providing practitioner guidance on confidentiality/disclosure of information
Developing guidance for commissioners to support the proposed Strategy's implementation.
At NHS Board level
2.10 During its deliberations on the proposed Strategy, the Reference Group considered it equally important that there is clarity of leadership and support for the Strategy at local NHS Board level. Responsibility for ensuring local implementation is given to each Director of Public Health (DPH), primarily because of the need to have clear lines of accountability both locally and nationally.
2.11 In responding to the proposed Sexual Health and Relationships strategy, each DPH should ensure that there is Board-wide
sexual health strategy (whether in existence or in development) which reflects the key components of the national strategy and which:
reflects local need
evaluates current service provision
promotes user involvement
identifies resource investment (current and planned) and
develops a phased approach to improving sexual health through enhanced service provision, health promotion, lifelong learning and identified actions to influence more general values and attitudes to sexual health.
2.12 This work should be developed through a
multi-agency, multi-disciplinary strategy group which reflects the composition of their local population. The emphasis is on developing and implementing a strategy which is owned by a range of agencies, not just the NHS and which includes actions for all the stakeholders with an involvement in the sexual health and wellbeing agenda.
2.13 In addition, the Director of Public Health should appoint a local
Sexual Health Co-ordinator who will support and be supported by the local sexual health strategy group. This co-ordinator should manage the network of all relevant sexual health providers and interests that contribute to the implementation of these multi-agency strategies (this is what is meant by a managed sexual health network). For some areas, this might mean a new appointment but for others it might be a redesignation of existing roles. The local sexual health co-ordinator will be complemented by the appointment of a local
lead clinician whose task will be to support the development of the tiered intervention approach (see Supporting
Paper 5A).
2.14 In addition to the above, local sexual health co-ordinators will focus on:
Ensuring that Community Plans and Local Health Plans address issues relating to sexual inequality, develop links between schools and services
Facilitating the development of lifelong learning opportunities, sexual health promotion and outreach services within a range of settings and for all ages as part of local strategy development and implementation
Supporting work with parents and carers
Implementing the recommendations of HIV Health Promotion Review Group
Developing a local training strategy based on needs assessment
2.15 The proposed Sexual Health and Relationships Strategy identifies a number of service and clinical targets for the improvement of sexual health and wellbeing: for example a maximum waiting time of 48 hours to access specialist sexual health services (Supporting
Paper 5A gives fuller detail). Feedback on the appropriateness of these targets will be sought as part of the consultation on the strategy. Once these targets have been identified, each local strategy should identify how these will be achieved locally. Plans including proposed investment and progress should be set out in Local Health Plans for monitoring through NHS Board Accountability Reviews and annual reports to the National Sexual Health Advisory Committee. It is proposed that implementation guidance will be provided at the same time when the final strategy is released for implementation.
2.16 Given their responsibility for education and social care and the links between sexual health and the wider social and cultural environment, Local Authorities are recognised as key partners in implementing sexual health strategies at local level. Local Authorities will be required to designate a
lead Director to progress the sexual health agenda through each Local Authority: This could be the director with the functional duty to promote health and welllbeing or the director responsible for children's services plans (in the latter case additional arrangements would be required to cover adults). Joint Health Improvement Plans, as part of Community Planning, should monitor progress and in particular identify partnership working initiatives in implementing the strategy.
2.17 Working in partnership with the voluntary sector and community-based groups (including faith organisations) will be essential to implementing the proposed Sexual Health and Relationships 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 and which will in part be achieved through the activities of the Sexual Health and Wellbeing Learning Network and if established, through the National Sexual Health Advisory Committee. In addition, there is potential for Voluntary Health Scotland to act as a link between the Advisory Committee and the wider voluntary sector.
At Community Health Partnership or locality level
2.18 The proposed Sexual Health and Relationships 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 may be a useful parallel arrangement to develop. 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. For some areas, this might also mean joining up with neighbouring areas for both service provision and to exchange ideas and experiences. One of the principles between Tier 5 of the tiered service approach is that they should be able to support the other tiers in terms of training and expertise (see Supporting
Paper 5A for further details).
3. Resources to support implementation
3.1 Staffing and other resource levels have not been set out in detail in the proposed Sexual Health and Relationships 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 the proposed Strategy. However, the Reference Group recognised the need to provide resources to "pump prime" the initial implementation stages so that a consistent approach could be made across Scotland. By providing such funding, the Scottish Executive could ensure that a "programme approach" to implementing the Strategy's recommendations is adopted throughout Scotland.
3.2 In addition, clear guidance on what is required as part of the implementation, particularly in terms of the tiered service approach, links between schools and services and information/data collection will be required: the Sexual Health and Wellbeing Learning Network will take this work forward in conjunction with key stakeholders (see website for further details -
www.healthscotland.com)
4. Monitoring and Evaluation of the Strategy
Benchmarking
4.1 Experience from elsewhere identifies the importance of being able to track both provider views and the wider public's views on the ongoing implementation of any strategy as well as tracking improvements in sexual health outcomes. This is important if we are to assess our progress in achieving "
a broad understanding ofsexual health and sexual relationships." In addition, it will link into the proposed work on developing a mass communications strategy as identified in Supporting
Paper 3.
4.2 The NATSAL survey and the Health Education Population Scotland (HEPS) provide a snapshot of the general population's knowledge, attitudes and lifestyles in relation to sexual behaviour. Neither currently explores detailed aspects of cultural and social attitudes or detail about specific interventions or services. The National Sexual Health Advisory Committee, in conjunction with key stakeholders, will consider the scope of including more detailed questions to assess the general population's views on timing, content and delivery of sex education programmes and to elicit views on sexual health service delivery. If undertaken, this would complement the user satisfaction work undertaken by individual service providers.
4.3 It will also be important to assess the impact the Strategy has had on service provision, from both staff and user perspective. This should be managed as part of an ongoing research and evaluation programme. The National Sexual Health Advisory Committee will consider the development of a tracking programme which will include an analysis of the effectiveness and impact of the Strategy in supporting and developing an integrated service approach.
5. Developing an evidence base for future work
5.1 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. There is a need to develop a sexual health research strategy for Scotland which takes account of the work of other agencies in this field (such as the Medical Research Council and the Health Development Agency) and is developed in conjunction with stakeholders at all levels. This will be an initial task for the National Sexual Health Advisory Group.
5.2 As part of the development of the strategy, the Reference Group identified a range of potential topics for consideration as set out below. Further discussions with other national organisations such as the Health Development Agency and the Teenage Pregnancy Unit, and local stakeholders, will help identify gaps that still exist and avoid duplication of work.
Evidence reviews
5.3 These reviews should combine needs assessment, an analysis of the effectiveness of differing methods of service delivery and organisation (thus linked to concept of evidence into practice) and recommendations for future policy. The topics for potential reviews identified include:
Research/Surveys
5.4 The suggested range of issues which should be considered for further research include:
Identification of potential barriers to partner notification (including harm arising from notification e.g. domestic violence)
Issues relating to "newly single" individuals
Media consumption
Further targeted interventions aimed at males (explore work based and non work based activities/approaches)
Development of non-invasive tests and their potential effectiveness and efficacy versus invasive test procedures
Extent and risk of female genital mutilation
Sexual health needs of lesbians
6. CONCLUSION
6.1 This supporting paper sets out the framework for taking forward the proposals contained in the draft Sexual Health and Relationships Strategy. This is intended to facilitate rather than hinder developments at national, regional and local levels. Notwithstanding this, strong leadership, clear accountability and appropriate resources will be paramount to help to progress the sexual health and wellbeing agenda in Scotland.
September 2003
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