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External Evaluation of Healthy Respect
A NATIONAL HEALTH DEMONSTRATION PROJECT: FINAL SUMMARY REPORT

II. Mapping partnership working and professional networks for sexual health

Hypotheses

In relation to the timed implementation of theHealthy RespectDemonstration Project, in Lothian compared with Grampian:

D. There will be significant change in the extent to which the service provider organisations in the initiative interact at a formal or institutionalised level

E. There will be significant change in the extent to which the service provider organisations in the initiative (or individuals working within them) network at an informal level

F1. There will be measurable or perceived benefit in the extent to which formal or informal connections and networks operate to the benefit of the client

F2. There will be a measurable increase or change in the way in which provider agencies (of medical and education services) interact with the client group and their carers

Government policy has supported the broadening of responsibility for health beyond the NHS to other agencies, has encouraged the development of inter-agency and partnership working, and promoted the idea of incorporating users' views in developing services. This level of the evaluation explored whether Healthy Respect had made a significant contribution to the broadening of responsibility for sexual health advice and services for young people through the development of professional networking and partnership working. In this level of the evaluation the objective was to evaluate the success of Lothian Healthy Respect in forging partnerships and networks

Comparisons of networking and partnership activity in Lothian and Grampian throughout the intervention period are made using regional inventories of services associated with sexual health service provision. These were compiled from interviews with professional staff and young people and from scrutiny of committee documentation and project reports.

D: To evaluate if there was a significant change in the extent to which the service provider organisations interact at a formal or institutionalised level.

In Lothian, after a hesitant start, Healthy Respect rapidly drew in partners to ensure extensive partnership working.

• At the outset of Healthy Respect with no Lothian-wide sexual health strategy in place, the evidence of strategic partnerships to improve the sexual health of young people was uneven, though earlier work around HIV had established some useful working partnerships.
• Three areas of Lothian had already developed strategic groups and action plans (West Lothian Sexual Health Promotion Group, Midlothian Young People's Sexual Health Promotion Group and the East Lothian Health Promotion Group) to enhance and increase service provision. In Edinburgh City no similar group existed at the outset of Healthy Respect.
• In terms of strategic partnerships, Healthy Respect was integral to the planning and shaping of both the local Lothian and the National Sexual Health Strategy documents.
• In terms of facilitative partnerships, Healthy Respect drew on both clinical and public health professionals and local authority partners to develop new forms of service delivery.
• Partners from the voluntary sector were also drawn in, and although small in scale and not as well resourced, these component projects were in a strong position to capitalise on the benefits of involvement with the demonstration project and used it to provide a new platform for the issues on which they worked.
• Voluntary sector involvement enabled Healthy Respect to benefit from work that was grounded in local communities or specific population groups, and to link with key agencies and individuals at an earlier stage than might otherwise have been possible.
• Partnership development was not a uniform process. Some potentially key agencies (e.g. community education and social work) were ignored or under-represented.
• Formal partnerships between the primary statutory service providers of health and education were slow and difficult to establish and more difficult to consolidate.
• Overall, however, this partnership working was a major achievement of Healthy Respect as it helped to raise the profile and the level of priority of sexual health work with young people in Lothian.

• By contrast, in Grampian, one strategy group met but no action plan had been produced at the beginning of the mapping process.
• This group had few connections and no partnerships with agencies outwith the NHS sexual health services.
• The later development of the Grampian Sexual Health Strategy was given urgency by the National Sexual Health Strategy development.
• Grampian Sexual Health Strategy development did not appear to link in a systematic way with work at a local level outside the health services. Although a considerable amount of strategic work with young people was going on in Grampian, with the Aberdeenshire and Aberdeen City Youth Strategies and with new community schools work, there was little evidence that this connected with the development of the Grampian Strategy.

E: To evaluate if there was a significant change in the extent to which the service provider organisations in the initiative (or individuals working with them) network at an informal level.

In addition to strategic partnerships the evaluation looked at whether informal networking existed in a way which might lead to better service integration. There will be significant change in the extent to which the service provider organisations in the initiative (or individuals working within them) network at an informal level.

The funding for the demonstration project in Lothian gave a significant boost to opportunities to develop informal networks.

• Healthy Respect gave many small voluntary organisations links to a more established and powerful platform from which they could work, and acted as a catalyst to promote dialogue between partners.
• Many of the networks that developed used Healthy Respect as the hub, but horizontal linkages between component projects soon started to develop, particularly among the voluntary groups.
• There were many networking opportunities in Healthy Respect, but there were also hidden costs to this volume of activity, particularly for local authority partners and smaller voluntary organisations. The latter often subsidised their involvement in the demonstration project.
• Practitioner level dissemination activities helped to develop some new networking opportunities with non- Healthy Respect agencies.
• Inter-professional training, which was developed as part of SHARE, offered informal networking opportunities for those involved. These were appreciated at the time but were subsequently difficult to build on or sustain because of the way in which the delivery of the initiative was managed in schools.

In Grampian some interesting developments took place in terms of efforts to develop sexual health advice and services for young people, but, without the catalyst of demonstration project funding, these innovations were largely uncoordinated, often arose from short-term funding and were poorly disseminated.

• Grampian initiatives were reliant on very short term funding and the commitment of key individuals who were themselves locally well networked.
• Where an informal group did come together the lack of any additional resource hampered its efforts to push forward any sort of sustained agenda.
• Uncertainty about the legitimacy of engaging in this area of work undermined attempts to develop sustainable networks particularly among youth work practitioners.
• Managerial support for such informal networking was uneven with little evidence of any continuing work throughout the period of the demonstration project in Lothian.
• In comparison to Lothian's extensive informal networking and opportunities, networking in Grampian appeared sparse and relatively unsupported.

F1: To evaluate if there was measurable or perceived benefit in the extent to which service provider connections and networks operate to the benefit of the client.

Evidence regarding this objective is to be found in data reported in Section 1A and 1B as well as in the data collected specifically for this level of the evaluation. Better networking might have been expected to lead to lower threshold services for young people, to easier referral through services, and to services where education and service provision were better integrated. The development of networks with a greater range of providers, including NGOs, might also have been expected to have increased the reach of services to vulnerable groups of young people.

With regard to Lothian, young people did start to receive a noticeably different style and level of service.

• The linked education package and service provision component of the SHARE projects was the most obvious Lothian attempt to provide low threshold service for some young people.
• Although the SHARE education work was of high quality (in terms of its theory base, training package etc), a relatively small proportion of young people in the Lothian catchment (about 20%) were exposed to it. The schools for the SHARE intervention were selected pragmatically, rather than systematically sampled for example from those areas of greatest need.
• The SHARE drop-ins provided low threshold access to services, and survey work reported in Section 1 shows that offer of such services made an impact.
• There was, however, huge variability in the operation of these services, and it is difficult to assess from the data kept by the drop-ins themselves what proportion of young people needing service were well served by these new facilities.
• Drop-ins which offered direct access to contraception were more heavily used than those which only offered advice and counselling.
• The localised nature of such service provision suited some fractions of the youth population, but was not perceived as anonymous or confidential enough by others.
• The mixture of formal and informal services at the drop-ins had different appeal to young men and young women, with the former preferring the casual drop-in element, and the young women making greater use of clinical one-to-one services provided.
• Younger adolescents liked the informal nature of the drop-ins as a venue for sating their curiosity and allowing discussion of issues which were normally 'out of order', but their boisterous behaviour was seen as jeopardising service provision for older teenagers. This problem was not well addressed.

In Grampian, on the other hand, there was little evidence of a sustained attempt to link education and service provision, to develop low threshold services or to improve service integration

• Attempts to link sexual health services with schools were, with a few notable exceptions, stifled fairly quickly.
• Without any strong strategic leadership in the area for the development of sexual health advice and services, and without the pressure for strategic partnerships to deliver, education and health services stayed almost entirely separate.
• School nurses seem to have played a larger role in Grampian than in Lothian, according to the survey work reported here. They operated a number of drop-in services in Aberdeenshire, but these were not routinely advertised.
• Localised attempts to develop a multi-professional drop-in service in another area were forbidden to advertise the sexual health side of the work within the local secondary school.
• Young people in rural areas felt particularly exposed by having to use adult services like GP clinics or outreach family planning services, but high costs of travel from the rural areas made access to more anonymous services difficult.
• Family planning services directly geared to young people were revamped to make a more attractive service to young people but remained highly centralised.
• A mobile bus offering contraceptive advice and services to young people operated via Health Promotions as an outreach into rural areas, but its coverage was limited and sporadic.
• One Moray initiative seemed to offer an innovative approach which drew in partners, including young people themselves to both the planning and development of a service in an outlying area.
• Community and youth workers were hampered in their attempts to provide support and service to young people on sexual health issues by a lack of appropriate guidelines, leaving them feeling professionally exposed.

F2: To evaluate if there was measurable increase or change in the way provider agencies interact with the client group and their carers.

This section considers whether partnership working or better networking allowed provider agencies within Healthy Respect to adapt their own policy and practice towards the provision of services for young people. Four aspects are focused on:

• changes in the way in which young people (and their parents) were consulted as service users;
• shifts in understanding in terms of the multi-professional contribution that could be made to improving young people's sexual health;
• changes in understanding about taking service to the client rather than expecting the client to come to the service;
• changing understandings about the different fragments of the youth population and the way in which service might have to be targeted towards them.

In both Lothian and Grampian there were many concurrent initiatives all aimed at changing service and thereby improving the life chances of young people e.g. new community schools, social inclusion partnerships, New Deal, Health Improvement funding, Sure Start, Excellence in Schools, and community regeneration support. Thus, throughout this section it is important to locate Healthy Respect's activities in the context of this wider array of initiatives trying to change the culture of service delivery to young people.

Participation and consultation with young people and parents as service users

In Lothian some attempts were made to develop consultation, but these often took the form of 'needs' assessments, where some professionals would argue that there is a 'rights' issue about young people's position as service users.

• Findings indicate that, even in Healthy Respect, consultation mechanisms and the participation of young people was generally poorly developed, with parental participation equally low. Few exercises moved above the level of "consultation" or "placating" rather than "participation".
• Consultation exercises about the Lothian drop-ins showed young people wanted longer opening hours, services at weekends and over holiday periods, service provision that included contraceptives and a holistic approach, but few of these demands were met.
• The virtues of consultation are sometimes hard for service providers to understand. Protracted consultation processes with parents and stakeholders over the development of the drop-ins in Lothian, for instance, delayed service initiation and delivery for young people.
• The participation of young people is viewed as even more difficult because of professional doubts over young people's competence to be part of the planning process.
• Consultation mechanisms with stakeholders were rarely innovative. Asking potential users to come to the service provider to give views is unlikely to result in high turn-outs or ensure wide representation or participation.

In Grampian, whilst consultation mechanisms with young people were well developed in other spheres (e.g. community development planning), they were largely ignored in respect of sexual health services

• Some innovative work in Moray (Support Made Simple) provided good exemplars of new ways of drawing young people in as planning partners.
• Health Improvement Funding supported a needs assessment on young people's health and well-being in three Aberdeen LHCCs in 2001. Findings of the report indicated that young people wanted to be involved in decisions about health service provision.

Multi-professional contributions to improving young people's sexual health

Multi professional working was a major aspect of the Healthy Respect work in Lothian.

• Multi-professional SHARE training was highly rated by Lothian staff undergoing training, but subsequent delivery of the initiative was much patchier. Such approaches need to be championed by management at senior staff level in school and at partnership level in local authorities.
• School nurses contributed to SHARE drop-in centres in Lothian, but their capacity was limited. Skilled professionals from many backgrounds contributed to the success of work in the drop-in centres. Young people appreciated recognising staff who had given SHARE sessions in school also delivering services.
• Healthy Respect tackled the thorny issues of developing confidentiality and child protection guidelines across professional groups. Conflicting protocols on these issues are notorious for spoiling attempts at joint working.

• In Grampian, without demonstration project funding, it was more difficult to draw different professional groups together.
• Partnership initiatives such as Walk the Talk, Social Inclusion and Health Improvement Funding attempted small projects to draw professional groups together in the service of young people's health.
• Education was often missing as a partner in many such schemes.
• In relation to sexual health education and services for young people work seems poorly supported, often unevaluated and not widely disseminated.

Partnership working to take services to young people

It is important for service providers to explore ways of taking service out to young people in places, at times and in styles which suit them.

In Lothian, Healthy Respect had a number of ways of tackling this challenge.

• Healthy Respect attempted to do this largely through the drop-ins.
• Healthy Respect also attempted, through several component projects to re-conceptualise the nature of service provision on sexual health, looking at issues which might have more salience for young people, e.g. by looking at issues of sexual coercion or gender uncertainty.
• Those who actually worked with young people undertook training on these broader issues, but were not themselves well-placed to drive the issues to the top of their organisation's agenda or ripple out learning to influence practice generally.
• GPs are the major provider of sexual health services, as the survey work shows. However, despite being key providers and gatekeepers they were not involved in any systematic fashion in Healthy Respect. Only the Parents project involved GPs in the development of the GP Birthday Card scheme, and only a small number of drop-in clinics did develop through GP practices, but with one exception these were not initiated through Healthy Respect. No mechanism existed to link with GPs and LHCCs over the development of the SHARE drop-in services.

Without the SHARE intervention, there were fewer attempts in Grampian to take services out to young people through drop-ins and so on.

• A number of drop-ins operated in Aberdeenshire, but in a very discreet way.
• A mobile bus service offering sexual health services for young people was sporadic in its coverage.
• Square 13, the city-centre family planning clinic in Aberdeen, did reorganise to offer more specific young people's clinics, but the service was very centralised and access to it for young people in rural areas was problematic, because of travel costs.
• Although GU services offered an outreach service in the Moray area in the final year of the study, local agencies including some health services, had poor knowledge of it.

Recognition of diverse needs of young people as a non-homogeneous group

Did new multi-professional ways of working cause service deliverers to appreciate the very different fragments of the youth population and the ways in which service might have to be targeted towards them?

Many lessons were learned in Lothian through the course of the first phase of Healthy Respect.

• Work within the drop-ins, as noted earlier, exposed the different needs of young men and young women.
• It also highlighted the different needs of young people of different ages, and also of those with and without sexual experience. All these groups made different demands on service which were not always compatible.
• The need to develop services that were sensitive to very different fragments of the youth population was appreciated within Healthy Respect around the needs of LGBT young people.
• There was little attempt to explore the need for services for ethnic minority young people.
• The absence of key agencies such as social work and community education from the Healthy Respect partnership was a serious gap in relation to work with some groups of socially excluded young people.

• In Grampian, recognition of the different needs of fractions of the youth population was not always matched by action.
• One multi-disciplinary group, the Sexual Health and Looked After Young People steering group was set up to meet the "Targeting Excellence" recommendations. These required development of appropriate health promotion and sexual health initiatives for young people looked after by the local authority (Report on the sexual health and looked after young people seminars, 2003). This group included medical practitioners, social work and public health. The report provides a wealth of information and advice but it is unclear at the time of writing, how this will be taken forward.
• Similarly, despite the development of an ambitious action plan for LGBT work by Aberdeen City Council in 2002, little evidence exists about implementation. It continues to be an area of work that is poorly supported. Outside Aberdeen there is little evidence of any work for LGBT young people at local level.
• No evidence was found of work with ethnic minority groups of young people on sexual health issues.

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