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ENHANCING SEXUAL WELLBEING IN SCOTLAND- A SEXUAL HEALTH AND RELATIONSHIPS STRATEGY: ANALYSIS OF NON-WRITTEN CONSULTATION EVIDENCE ON THE DRAFT SEXUAL HEALTH AND RELATIONSHIPS STRATEGY
CHAPTER SEVEN SUPPORTING CHANGE
Leadership and accountability
7.1 The draft strategy proposes a framework to champion sexual wellbeing at all levels, to ensure a high profile for sexual health issues amongst competing resource demands and to enable a multi-agency response to the development and implementation of the strategy at national and local levels. 7.2 At a national level, the draft strategy recommends that the Scottish Executive should appoint a National Sexual Health Programme Co-ordinator who should be based within the Scottish Executive. It also recommends the appointment of a National Sexual Health Advisory Committee, chaired by a Scottish Executive Minister, to guide the implementation and ongoing development of the strategy. It is also intended that there should be an annual report on national progress of the strategy and a five yearly review. |
7.3 The national co-ordinator post has been labelled as a 'sex tsar' both in the Parliamentary debate and in discussion amongst research participants. Many of the SCF participants met the idea with cynicism.
"A good 3 or 4-year campaign could be run on the money that a 'Sex Tsar' would cost. Evidence-based research would be of much more use in improving sexual health than a Minister" (SCF participant).
"A 'Sex Tsar' is not a priority. Reliable and locally available information is the key. Would appointed Sexual Health Co-ordinator mean that all other employees would not bother addressing sexual health issues? Co-ordinator's jobs should be about linking up all those working to deliver the strategy. Sexual health needs to be integrated into everyone's work" (SCF participant).
"A 'Sex Tsar' is not a good idea. Local authorities need to be available to lobby to change" (SCF participant).
"A Tsar would be too expensive - it would take money away from education" (SCF participant).
"Do we want a Sex Tsar? Like the so-called drugs tsar that Westminster had for a while, he just came and went. There was no evaluation. He seemed to hold his own point of view and didn't listen. Having a 'Sex Tsar' won't solve anything" (SCF participant).
7.4 There was some support for the National Co-ordinator, Advisory Committee and process of review with recognition of the challenges of their task.
"These appointments are a positive measure. A Co-ordinator and Advisory Committee need to be implemented to give the recommendations teeth, to provide leadership on the issue and hold the Executive to account. These people could campaign for additional finance and allocate funds" (SCF participant).
"It is good that the committee is an advisory committee and not authoritative. The Committee and co-ordinator should express their views as part of an iterative process or debate, rather than as the final word on issues. That way they can in effect carry out a debate with society. It is good that there is no final answer and they are constantly responsive to views" (SCF participant).
"Sexual health is such a broad area that it does deserve this kind of priority. It's a relief that government have finally brought this up. We need to start changing things now so our sexual health can improve in the future" (SCF participant).
"5-year reviews could be used to look at the targets" (SCF participant).
"Champions will have to face the public, put the message out without fear or favour" (SCF participant).
7.5 However, there were also some concerns over accountability and representation on the proposed Advisory Committee.
"The representation on the proposed Advisory Committee needs to be wide, inclusive and representative" (SCF participant).
"There should be faith community representatives on the Advisory Committee" (SCF participant).
"Parents should be on the committee - for example school boards, Parent Teacher Associations, Scottish Parent Teacher Council and other parent networks" (SCF participant).
"The membership of the committee needs to be wide and its workings should be as open as possible to the general public" (SCF participant).
7.6 In the draft strategy, NHS boards are seen to be the most appropriate body to co-ordinate and lead local action, in partnership with key stakeholders. Local leadership through local sexual health strategies and sexual health networks and local co-ordination is seen as key to implementation. Local authorities are seen as key partners in implementing the strategy at a local level, given their responsibilities for education and social care and the links between sexual health and the wider social and cultural environment. It is recommended that local authorities should designate a strategic lead for sexual health. They should also ensure that Joint Health Improvement Plans, which are part of Community Planning, should detail partnership working to address specific sexual health issues and the wider determinants identified in the strategy. |
7.7 Participants in the SCF discussions did address these issues that relate to the need for cross-departmental representation and working particularly in relation to education and Community Planning.
"Why is the focus on the Health Department in this strategy? The Minister for Education, Minister for Communities, and all others need to be involved. The responsibility for the sexual health strategy needs to lie with more than one Department" (SCF participant).
"Sexual Health needs a lead Department in government, not a new one of its' own. The subject links well into Community Planning. That would make it consistent across the country" (SCF participant).
"The responsibility for the sexual health strategy needs to lie with more than one Department. The Minister for Communities should share the Health Minister's responsibility" (SCF participant).
"At a local level, the strategy should be linked into Community Planning" (SCF participant).
7.8 There is a clear preference to see resources directed primarily towards those working at community level although no consensus on the relative merits in terms of accountability and representativeness of health boards and local authorities.
"The Health Boards need to take ownership and responsibility for the problem, including their own role in propagating it" (SCF participant).
"I don't think the Health Board should be used to manage the strategy or funding. They are not accountable enough. The Local Authority is the democratically elected body, so they should hold the remit" (SCF participant).
"Allowing the Local Authority to guide the process would allow for a multi-agency approach" (SCF participant).
"The council are old men, the very people who make sure the taboos and prejudices stay in place. The Health Board has a social and medical perspective, and so would give the strategy a much more positive approach" (SCF participant).
"Local Authorities are elected by the people, so we are able to change the people on it if we don't like their approach" (SCF participant).
"The Minister for Health is able to pull rank with local health boards, and push their activities in any direction desired" (SCF participant).
"Putting responsibility at Health Board level - they are meant to be experts, but this will not be very democratic. There is no accountability in local health delivery at the moment. Shared responsibility is needed amongst all health care professionals" (SCF participant).
7.9 The draft strategy also sees partnership with the voluntary sector and community-based groups (including faith organisations) as essential to implementation at national and local levels. Whilst recognition of the role of the voluntary sector was welcomed, participants had concerns about the burden on the voluntary sector and the likely level of resources to fully implement the strategy.
"Promoting sexual health should not lie just with specialists. Responsibility should lie with everyone who works at ground level. The point of first contact is often the most important to people. Workers don't have to be experts - just well informed" (SCF participant).
"The approach needs to be more clear on the nature of any cross-agency work between voluntary and statutory sectors. There are hundreds of strategies on the go at any given time. Maybe some of them could be merged?" (SCF participant).
"The strategy needs to form on a basis of equal partnership between the voluntary and statutory sectors. Different organisations could work together, and allow what money there is to be spread around more" (SCF participant).
7.10 The draft strategy proposes that there would be clear national and local targets and goals and on-going monitoring of progress to ensure delivery by the new Advisory Committee at national level and Directors of Public Health at local level. Some participants had already expressed doubts about some of the proposed targets, for example, that of reducing teenage pregnancies. Other participants were also concerned and linked this issue back to the question of the representativeness of the Advisory Committee.
"We don't trust the government. Any board running this strategy would have to be representative. Who sets the targets and goals? How are faith groups going to be represented? The idea of 'setting clear local and national targets' - does that allow the morning after pill to be given out in schools? Apparently so!" (SCF participant)
8.
7.11 It is also proposed that NHS Health Scotland should disseminate evidence, commission research and develop resources to support the ongoing implementation of the strategy, including enhancing existing lifestyle surveys to provide feedback on the target groups of the draft strategy. |
7.12 In relation to this and the proposed clinical standards and service targets for STIs and data collection, participants made no specific comments.
Staffing and other resources
7.13 The draft strategy recommends that the Scottish Executive should provide resources to NHS Boards to 'pump prime' the initial implementation stages of this strategy. The strategy does not set out staffing and other resource levels in detail, as it is seen as being the responsibility of individual NHS Boards and their Community Planning partners. |
7.14 Participants raised a number of concerns about the level of resources to be available to implement the strategy, particularly over the longer term.
"A long-term view must be taken on this strategy. The expression used in the strategy - 'pump-prime' - suggests that this will attract three years of funding and that will be it" (SCF participant).
7.15 There was concern about the apparent levels of bureaucracy that the draft strategy was suggesting and a call was made to push what resources there would be towards the ground level, where the work was being done.
"There are too many tiers of expenditure before any money gets to the workers at community level - too much bureaucracy" (SCF participant).
"The budget will be crucial to this whole strategy. How much money goes in will determine how successful it is. Where will the money come from? Will it be robbed from another programme?" (SCF participant).
7.16 It was also suggested that the draft strategy should evaluate existing services and build on them, rather than fund new ones.
"The strategy should be about building on and strengthening current structures not creating new ones and yet another tier of bureaucracy" (SCF participant).
"It's not all about money. It is much more important to reorganise the services that already exist. Assess what is already working well and use the available funding to finance those services" (SCF participant).
Education and continuing professional development
7.17 The draft strategy recognises that staff at all levels and in all sectors will need increased knowledge and skills on sex and relationships. It recommends the development of a national sexual health training strategy to provide generic and specialist skills in sexual and reproductive health. NHS Boards should also develop joint training for health and Local Authority personnel to develop core skills in communication, attitudes and relationships addressing the wider social and cultural determinants of sexual health. Training would therefore include those whose remit is not solely sexual and reproductive health, for example, staffing working in Accident & Emergency, general medical departments, teaching staff and social care staff as well as parents and carers. |
7.18 Participants endorsed the view both of the need for training and the need for it to encompass a wide range of people, particularly staff who have a wider remit than sexual health and wellbeing.
"There are too many chiefs in this strategy. Training for staff on ground level is needed" (SCF participant).
"To be holistic, the strategy needs to recognise the importance of frontline workers. Training, support and education will be essential for these people" (SCF participant).
"Resources are needed to enable inter agency working. Frontline workers (mainly sessional workers or youth workers) need training and support. They should not be used as casual labour" (SCF participant)
"Training has to be given to those who work with people in our communities such as paid carers, all primary health care staff and teachers on sexual health and well-being, the strategy and sign-posting" (SCF participant).
"An awareness of sexual issues needs to go into training of medical and related professions such as Occupational Therapists and Physiotherapists. Some professionals don't see it as their role, but the working relationship they have with the patient could be the best basis for raising a discussion. They don't want to be sexual counsellors, but they could refer on. They play an important role in 'permission giving' - in reassuring the patient that their concerns are legitimate" (Consultant clinician interview).
7.19 The need for the development of cultural competence raises issues about training for a range of professionals and health practitioners and how best to develop their confidence to raise sexual health issues and refer on appropriately.
Developing an evidence base for future work
7.20 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. The draft strategy therefore recommends that the National Sexual Health Advisory Committee should develop a sexual health research programme for Scotland in partnership with key policy, research and practice stakeholders in Scotland and elsewhere. Supporting Paper 6 identifies potential areas for future work and suggests that further discussions will help to identify gaps in the evidence base
9. 7.21 A number of evidence reviews are proposed tocombine needs assessment, an analysis of the effectiveness of differing methods of service delivery and organisation and recommendations for future policy. The topics for potential reviews identified include: 7.22 A range of issues were also suggested for further research including: dentification 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
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7.23 The main gap in the research evidence identified during this research relates to issues relating to older people, as discussed in
Chapters 3 and
5. It was suggested that much of what exists tends to be rather medical, but that as a starting point there is scope for a literature review.
7.24 In relation to those recommendations in the Supporting Change chapter of the draft strategy on which participants made comments, there was support for the need for change. There was some scepticism about the proposed framework to champion sexual wellbeing at all levels but also some support and recognition of the challenges of the task. There were concerns over accountability and representativeness and worries that the framework will be too bureaucratic. There was a clear preference expressed for resources to be directed to those working at community level, although no consensus on the relative merits of Health Boards and local authorities as lead agencies. There were also concerns about the level of resources that are to be available to implement the strategy, particularly over the longer term. There was support for the need for training on sex and sexual relationships to encompass those who have a wider remit than sexual health and wellbeing.
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