ENHANCING SEXUAL WELLBEING IN SCOTLAND - A SEXUAL HEALTH AND RELATIONSHIPS STRATEGY: Analysis of Written Responses to the Public Consultation
CHAPTER 11: SUPPORTING ACCESS TO SERVICES
11.1 In general, responses were positive about proposals regarding access to health services (except in relation to accessing terminations in a short space of time). Health Professionals were also positive but had particular concerns about funding and resources.
Lead Clinicians should ensure barriers that restrict the use of services are identified and addressed
Local Sexual Health Co-ordinators should ensure that proposals to improve service access for all populations are identified in the NHS Board inter-agency sexual health strategy
Lead Clinicians should ensure that all clinical services have assessed their current services against the service values and principles identified in Box 7 of the national strategy
Local Sexual Health Co-ordinators should ensure that proposals to address identified deficits are included in each NHS Board's inter-agency sexual health strategy
11.2 There was general agreement that actions need to be taken to identify and address the barriers that restrict the use of services. It was noted that this includes a range of issues and groups.
"…the need for information and resources that are accessible to people with profound and multiple learning disabilities is imperative. This means having 3-D objects or tactile leaflets to name a few." (Equalities)
"Deaf awareness doesn't have as much focus as general disability awareness and needs to be treated as a separate subject." (Equalities)
"This is a helpful section [which helps to identify] the context of a problem encountered by young people in a rural area i.e. confusion over availability and issues and perceptions around anonymity/confidentiality. Opportunities for joined-up working with other agencies including training around protocols is important." (Education and Young People)
SUPPORTING ACCESS TO SERVICES - DEVELOPING PROFESSIONAL ROLES
11.3 There was broad agreement in relation to the development of professional roles but several key concerns in relation to service delivery and funding were identified.
Lead Clinicians should ensure that GPs and other primary care staff are supported in their initial and ongoing training needs to contribute to the tiered service approach (and linked to the ongoing training needs analysis included as part of the development of local sexual health strategies)
11.4 There was a concern that this might take GUM Clinicians and GPs away from their patients to attend training.
"Agree but note problem of back-filling for sexual health staff called away to train others" (Medical Health)
The Primary Care Division of the Scottish Executive Health Department should consider means of enabling GPs to play a key role in the delivery of this strategy. This should include exploring the potential of extending the General Medical Services contract
11.5 There were some grave concerns (discussed earlier) relating to the role of GPs in delivering GUM services. A conflict was identified between the apparent key role identified for GPs and their ability to opt out of providing GUM services.
"It would appear from initial discussion that the enhanced service of sexual health is not going to be purchased by the PCO from GPs (…) I have grave concerns that the Sexual Health Service will now be centralised and subsequently removed from Primary Care." (Medical Health)
"We are concerned about the operation of the GMS contract and worried that GPs will opt-out of GUM provision. This is not tackled in the strategy. (Medical Health)
11.6 It was also noted that there are issues around the out-of-hours opt out in the GMS 2 contract - surgeries may only be open 8.30am to 6pm Mon-Fri and this "would not provide the level of flexibility and choice suggested in the Strategy."
The Postgraduate Medical Deans, professional bodies and NES should address the issues affecting the career progression of those doctors specialising in family planning and reproductive health
11.7 This was broadly supported but it was noted that there is a need for an expansion in Scottish specialist registrar GUM posts given the current "gross under-provision" of GUM consultants.
NES, in conjunction with professional organisations and NHS Boards, should develop training and resources to enable the further extension of nurse led sexual health services in primary and secondary care
11.8 There was considerable support for further extension of nurse-led sexual health services but there were significant concerns about whether there is capacity for this. Some Practice Nurses were concerned about how they could accommodate sexual health work without increased resources (including premises).
"The strategy is based around nurses taking on enhanced roles, especially practice nurses. There is a little capacity left for this." (Medical Health)
11.9 It was also suggested that an expansion of Sexual Health Nurse Consultant posts would be desirable as there is currently only 1 in Scotland.
SUPPORTING ACCESS TO SERVICES - RURAL SERVICES
The National Sexual Health Advisory Committee should review the needs of rural communities as an early task and where necessary identify further action to be taken
11.10 Difficulties in access to services in rural areas was a recurring concern throughout the consultation responses, particularly from Equalities Groups, Health Professionals and those representing young people. Many issues were identified which need to be addressed - the difficulties young people face in accessing services outside school hours, difficulties in referring people on to services, difficulties providing a choice of service providers, difficulties providing confidentiality in small communities etc.
11.11 It was particularly noted that there are wide disparities in GUM services across the country.
"In Dumfries and Galloway, Western Isles, Orkney and Shetland there is no specialist GU Medicine service available. (…) While cross-board networking may help some regions, most neighbouring areas have almost nothing to network." (Medical Health)
11.12 However, it was also noted that rural location isn't the only thing that prevents young people in particular from accessing clinics. Urban areas may have "territories" and young people in one school may not go to a clinic in another school's "patch".
SUPPORTING ACCESS TO SERVICES - INFORMATION
NHS Health Scotland, in partnership with local sexual health promotion specialists and the Sexual Health and Wellbeing Learning Network, should develop practitioner guidance so that information and health promotion materials challenge, not reinforce or replicate, stereotypes and reduce, not increase, misinformation and discrimination
Sexual health service providers in each NHS Board should review existing service information, revise and make this available in a range of easy to read and accessible formats (and where necessary in language and formats appropriate to local population needs)
Lead Clinicians and local Sexual Health Co-ordinators should ensure that standardised evidence based information on sexual health and service provision is available for both professionals and service users
Lead Clinicians should ensure that referral protocols for accessing services within and across each tier are developed and known to all potential referrers
Lead Clinicians should encourage service providers to combine sexual health promotion messages with information on specific health issues as part of an individual's consultation
NHS 24 should develop algorithms which provide accurate and appropriate advice consistent with that given by sexual and reproductive health service providers
NHS 24 and service providers should ensure ongoing exchange of up to date and relevant service information
11.13 Few responses referred specifically to the recommendations in this section. Generally it was noted that all information and materials should be developed so that they are appropriate to the needs of all groups in society (for example visually impaired, deaf people, those with learning difficulties etc).
"The group would wish to see graphic and aural versions of material made available for people with low literacy levels and those who cannot read." (Equalities)
"For people with learning disabilities, there is a need for provision to be made for the education and/or support of carers" (Equalities)
SUPPORTING ACCESS TO SERVICES - CONFIDENTIALITY AND ANONYMITY
The National Sexual Health & Wellbeing Learning Network, building on evidence from Healthy Respect and in conjunction with all relevant stakeholders, should develop guidance on confidentiality/disclosure of information for use by all service users and for all relevant health, social care and education staff
All providers of sexual health advice, information, learning and services should prominently display their confidentiality approach in information booklets, on notice boards and in waiting areas
Service providers should give clear information to users about their options when giving personal and identifiable information if confidentiality and/or anonymity are of concern
All laboratory requests should be anonymised regardless of referrer. NHS Boards, through Lead Clinicians, should ensure uniformity of recording of patient details across all providers (and thus address anomalies between GUM and primary care record keeping)
11.14 There were mixed views from medical professionals in relation to the anonymity of laboratory testing. The majority were in support of the recommendation but there were some concerns that this could impact on patient care. Generally, more clarity is required to specify exactly what is meant by anonymity and who this affects. The guidance on confidentiality was welcomed though.
"This is an interesting idea which we support but in practice will require extensive piloting. We would recommend specifically that sexual health service IT systems and requests from primary care for STI tests are exempt from using the CHI number system." (Medical Health)
"The recommendation on standardised procedures for ensuring anonymity of lab tests seems unclear. The anonymity offered by GUM services cannot be offered to those accessing Primary Care services as most people will be known to and have a relationship with practitioners. If this recommendation is rather about keeping results from sexual health laboratory tests separate from general medical notes then the recommendation should reflect this." (Medical Health)
"Anonymisation of specimens could hinder patient care if a person approaches a different service provider (or is admitted to secondary care) and results taken elsewhere cannot be readily accessed." (Medical Health)
"In the case of cervical screening, the programme would be fatally undermined if records cannot be linked." (Medical Health)
11.15 However, another perspective suggested that a focus on anonymity perpetuates the stigma associated with STIs.
"The emphasis on anonymity of testing perhaps perpetuates the stigma of the old "VD clinics" era. Individuals who appear at family planning clinics for STI screening have named tests. This illustrates the two views on this situation - the DATA Protection extreme in using numbers only as in GUM clinics at present, or using names and making it normal and accepted as with any other kind of medical test or intervention." (Medical Health)
SUPPORTING ACCESS TO SERVICES - CONTRACEPTION AND TERMINATION
Lead Clinicians should ensure that local standards on agreed competencies, confidentiality, access to and provision of contraception are developed
Lead Clinicians should ensure that there is access to, and provision of, all methods of contraception and that staff have appropriate skills/can demonstrate competency to agreed standards
11.16 Few comments were made in relation to this, but those made were generally supportive (except in relation to young people). Specific comments related to the role of Community Pharmacists in providing contraception and the needs of those with learning difficulties.
"Should support national development of free emergency contraception through community pharmacies." (Medical Health)
"Good guidance needs to be given to people with a learning disability on the pro's and con's of each contraception and which one would be best suited to the individual. This information also needs to be non-judgemental i.e. only recommending sterilisation if that really is the best option, not because it's convenient." (Equalities)
Lead Clinicians should ensure there is access to appropriate termination of pregnancy services, which meet national standards. As a first step, services should ensure access to termination within three weeks of initial consultation. Services should work towards reducing this target to one week by March 2006
11.17 The proposals relating to accessing termination attracted a great deal of attention and strength of feeling. Over a third of all responses disagreed with the targets to speed up access to termination. A significant minority believed that the proposals were offering termination as a form of contraception and promoting its use as such. Issues around termination are highly emotive and this was clearly demonstrated in the consultation responses. There were perhaps two main differing perspectives from Individual and Faith Groups respondents on the proposals relating to accessing termination.
11.18 First, a significant minority were completely opposed to termination as a matter of principle and were offended and angered by the Draft Strategy.
"It seems clear that the strategy seeks to perpetuate the silent holocaust of the unborn." (Individual)
11.19 Second, over a third of all responses, regardless of their view on the principle of termination, were strongly opposed to enabling access to termination within one week. The majority of objections to the proposals focused on the fact that the proposed speed of access would not enable women to make informed decisions based on all the options available. It was felt that there should be more time for pre-termination counselling and more emphasis on alternatives to termination such as adoption.
"Reducing the referral time for an abortion will not allow men and women the space they need to work out what is the best decision for them. Time is required for counselling so that they have all the information they need and have looked at each option open to them." (Social Health)
"A young woman needs time to look at all the options to make an informed personal decision." (Individual)
"[Abortion within a week] is insulting and abhorrent to anyone who upholds the value of life." (Individual)
11.20 There were particular criticisms of the fact that the Draft Strategy acknowledges issues around post-termination trauma but still condones quicker access to terminations rather than enhanced counselling services.
"Why are you recommending easier access [to abortion] when you are already aware of the damaging implications?" (Education and Young People)
"I was glad that the Strategy recognised 'the unresolved emotional impact' of abortion on women but was dismayed at the simultaneous proposition to make abortion available within a week of initial consultation. Surely this awareness of the hitherto neglected psychological and emotional issues involved in abortion should lead to caution, re-evaluation, investigation into these too-frequent incidences, rather than a rush to make abortion all the more accessible." (Individual)
"Young women need to be protected from, not rushed into, such a dangerous procedure." (Individual)
11.21 However, other responses from different respondent groups offered an alternative perspective. Health Professionals in particular agreed that services should be more quickly accessible and that there should be equitable services across Scotland.
"In particular, we endorse the target to reduce waiting times for termination to one week. We feel this would be easier if women could self-refer to termination services and thereby avoid delays caused by difficulties of getting a referral in the first place." (Education and Young People)
"We feel it is important to reduce the time limit between outpatient's visit and termination but that time limits should retain the opportunity for a short cooling off period for women." (Social Health)
"There are considerable variations in the levels of service available to women for termination of pregnancy across Scotland. This is an urgent area requiring national leadership … we believe that there should be a national requirement for Health Boards to provide timely, accessible and high quality termination services." (Medical Health)
"[Organisation] is pleased that the proposed strategy contains the target to ensure that all women who meet the legal requirements are able to access an NHS abortion within three weeks of initial consultation, working towards a one-week target by March 2006. However, the delays which some women currently experience - of up to four to five weeks - will challenge the achievement of this target." (Medical Health)
11.22 It was noted that another approach to aiding access to termination services would be to introduce a central referral system, self-referral and direct access to a gynaecologist to reduce delays. There was a concern that in some areas GP referral may be an obstacle. One respondent also suggested that consideration be given to providing termination services at home.
Lead Clinicians should ensure that the RCOG guidelines on the "Care of Women requesting Induced Abortion" are adopted by services in their NHS Board area
11.23 This recommendation was supported by many in the medical and social health professions.
"There should be a national audit of current care provision against standards derived from the RCOG guidelines 'Care of Women Requesting Induced Abortion'". (Medical Health)
Women who have had a termination should have their contraception needs addressed prior to hospital discharge and referrals for ongoing or future support should be made
Training programmes to enable staff to respond to the sexual and reproductive health needs of women and their families following termination, miscarriage and stillbirth should be provided. Local Sexual Health Co-ordinators should ensure this is incorporated into the local inter-agency sexual health strategy (paragraph 5.24)
11.24 Few commented on these recommendations, although it was noted that midwives could play a key role in relation to providing these services.
SUPPORTING ACCESS TO SERVICES - SEXUAL DYSFUNCTION
11.25 Comments relating to these recommendations came largely from the Medical Health Professionals, including community pharmacists. Generally, there was a perception that current services and prescribing guidelines were too restrictive.
NHS Boards should provide support and resources to enable a wider range of general health care professionals to respond to their local population's sexual dysfunction needs
"Agree. Agencies such as Relate, Couple Counselling, etc. should be included in the 'range of general health care providers" (Social Health)
"Local couple counselling and Sex and Relationship Therapy services already play a significant part in service provision, which is very cost effective. Investment of public funds in increased training provision and service delivery would make a major contribution to the level of services available across Scotland." (Social Health)
"Inclusion of psychosexual services is most welcome. It is important to promote partnership working between specialists across agencies, e.g. psychology, family planning, neurology, couple counselling, etc." (Social Health)
Commissioners in each NHS Board should ensure that services are available to meet their population's sexual dysfunction needs
"Current provision of drugs for Erectile Dysfunction is too restricted" (Medical Health)
"[Organisation] sees no reason why prescription on the NHS of orally-active agents for sexual dysfunction should continue to be restricted to a small list of specialists and asks this be reviewed" (Medical Health)
"[We welcome] the acknowledgement of this particularly sensitive sexual health matter….. however, current prescribing guidelines are particularly restrictive and insensitive to individual needs" (Medical Health).
"Sexual dysfunction clinics are usually overwhelmed and have long waiting lists and most rely on the charitable sector to do the work … There should be services provided or referrals offered in other clinics" (Social Health)
"Such work needs to ensure that different sexual responses, especially those of women, are not pathologised, and that heterosexual penetration is not viewed as the only option." (Equalities)
Lead Clinicians should review current services so that men with erectile dysfunction have a specialist assessment within three months of initial referral (working towards one month in the long term)
11.26 There were some general concerns about accessing sexual dysfunction services in some areas and for some groups. It was noted that there are no services for Erectile Dysfunction in some areas of Scotland.
"The provision of training for a wider range of staff to take on the needs of those with sexual dysfunction may be the only way of providing some sort of service for areas where there is no consultant led service. This point is supported, however, sexual dysfunction needs to be balanced against other needs for contraceptive services and STIs, which it could be argued, is a more basic need which has not been addressed locally." (Medical Health)
"[The strategy] could pay more attention to sexual dysfunction in women" (Medical Health)
"It is inequitable to include a target for male sexual dysfunction and not female. There will be resource implications for meeting such a target for men and women" (Social Health)
"We would fully support (4.70 page 61) in encouraging NHS Boards to review their current arrangements for prevention, treatment and referral for sexual dysfunctions" (Social Health)