The Scottish Government

Clinical Workshop held in the Radisson SAS Hotel, Edinburgh on February 16 2005

Key Points/Summary

• There is great enthusiasm in the family planning and GUM community for taking forward the sexual health strategy and action plan
• New money (£5 million per year for three years, total £15 million) should primarily be spent on frontline services
• Progress on implementing the strategy may figure in NHS boards' annual accountability review
• Sexual health in Scotland is poor, services have been under-resourced historically and access is patchy across the country
• Issues include capacity, inadequate premises, recruitment, retention and training of staff, national and local leadership and poor facilities including access to laboratories, IT and data collection
• There are particular issues for remote and rural areas, especially around access to services
• Managed clinical networks could provide a good way forward
• There is political will to make improvements and opportunities brought by the strategy should be seized
• NHS boards should already be acting to draw up initial plans by 31 March 2005.

Introduction

Representatives from each of Scotland's 15 NHS boards attended a clinical workshop in Edinburgh on 16 February 2005 to discuss taking forward the Scottish Executive's newly published sexual health strategy and action plan.
Around 40 people attended. Most were clinicians working in the sexual health field, including specialists in family planning and genitor urinary medicine (GUM). Health promotion and NHS management were also represented.
The meeting was hosted by Professor Peter Donnelly, Deputy Chief Medical Officer and was attended by senior Scottish Executive Health Department officials and by representatives of SEHD's Centre for Change and Innovation.
The day was structured around presentations from Professor Donnelly and from two clinicians working in frontline services and regional workshops looking at challenges, solutions and the way ahead.

Political Context

The Scottish Executive published its sexual health strategy, Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health on 27 January 2004.

It was based on the work of an expert reference group and an extensive public consultation.

Mr Andy Kerr, the Health and Community Care Minister, promised £15 million extra funding over the next three years to implement the strategy, which was developed against a background of poor teenage pregnancy rates and rising incidence of sexually transmitted infections.

The majority of the additional money will be used to improve frontline services (source: press release on strategy launch).

Mr Kerr took the unusual step of saying he would take personal charge of the strategy, rather than appoint a sexual health lead clinician (or tsar) nationally. He will personally chair a National Sexual Health Advisory Committee.
He also made it clear in a letter to NHS board chairmen that he attached great importance to the progressive implementation of the Strategy and Action Plan and asked them to personally ensure that action is taken forward expeditiously within their Board area.

The strategy sets out action points for stakeholders including NHS boards, local authorities, the Scottish Executive and other agencies.

Key recommendations affecting NHS boards include:

• each NHS board will nominate an executive director and lead clinician to take the strategy forward
• NHS boards should review services and look at ways of improving them and widening access
• An inter-agency local sexual health strategy is to be developed

Presentations

Professor Peter Donnelly, the deputy CMO, opened the meeting by reminding the audience that they were there to discuss how the strategy would be implemented, not to 'further strategise'.

He stressed that the minister had taken ownership of the strategy which helped make it 'matter' in a political context. He said the new money - £5 million a year for the next three years - should be spent largely on improving frontline services.

He said NHS boards should come up with plans by the end of March so that money can be released to improve services.
Existing services should be reviewed to ensure every pound was being spent in the right way and ways of working 'smarter' should be explored.

Priorities included widening access to services and seeing where family planning and GUM could be integrated.
He called on the audience to focus on where services in their area could be directly improved, whether working on a local or regional basis.

Above all he made it clear that he wanted a two-way approach to implementing the plan with ideas coming from the frontline, not imposed by the Scottish Executive. He said the political climate was favourable and the money there so urged those in the field to seize the tremendous opportunities on offer for what had, in many ways, been a neglected area.

GUM: The reality

Dr Rak Nandwani, GUM specialty adviser to the Scottish Executive Health Department and consultant in Glasgow, outlined the challenges facing Scotland's GUM services. In essence, despite extensive modernisation, GUM services are still struggling to meet rapidly increasing demand. Access to services depends on where you live.

The major challenges are insufficient capacity, long waiting lists and missed calls, and less staff than other specialties (and less than in England). GUM services cannot meet current demands despite best efforts.

There are areas of good practice in Scotland. GUM is able to provide specialty functions not available from any other sexual health providers - for example, near-patient testing, one-stop clinics. partner notification, management of complex STIs and large volume HIV testing. GUM services are also accessed by men and women of all ages, including hard-to-reach groups (such as men who have sex with men), which gives good opportunities for general health promotion. But services are patchy and some NHS boards don't even have a GUM consultant.

There is also the difficulty that GUM services are very personal so there is a lack of a patient voice - there's no 'chlamydia survivors' group campaigning for better services, for example.

He suggested a number of solutions. First, boards should admit there is a problem, ensure they each have family planning and GUM expertise and build capacity so that anyone likely to have an STI is seen within 48 hours. He suggested that community health partnerships could facilitate local access.

He also pointed people to the 'tiered' approach (from self-management to specialist services) in the draft sexual health strategy as a possible way forward.

He said managed clinical networks for the North, East and West of Scotland with a hub and spoke model in each would be required.

Finally he said the new focus on sexual health was a real opportunity, that new resources must increase capacity, that it must not be diverted to existing overspend, local and national leadership was essential as was staff recruitment and training.

Family Planning: The Reality

Professor Anna Glasier, consultant in family planning and well woman services in Lothian described the history of family planning services, the current situation in Scotland, the challenges and the way forward.
Capacity, staffing and premises are the major problems.

There are 14 family planning services in Scotland, three are large central services with peripheral clinics, five are consultant led, and two are merged with GUM. There are also voluntary sector services for young people.

Family planning offers real value because it empowers patients, gives them choice and gives them a service (eg for people with complex contraceptive needs) which they cannot access elsewhere. Women like it, patient numbers are growing and services are expanding to take in reproductive health such as menopause clinics and cancer services. There is also evidence that women using long term contraceptive methods (often only available from specialist family planning services) are more likely to stick with them and therefore more likely to be protected from pregnancy. This is key to meeting the aims of the strategy.

Family planning has also pioneered skill mix and extended roles, particularly for nurses. It spans primary and secondary care and provides training.

On the negative side, staffing is woefully inadequate. There is also a lack of consultants which means the service does not have 'clout'.

There are also major problems with premises, IT (including data collection), access to laboratory services and to support services such as procurement.

What is required is a critical mass of well-trained staff in consultant-led services, which means appointing more consultants now and ensuring a steady stream of three full time family planning trainees each year.

Prof Glasier called for investment in personnel, in premises, in modern facilities and IT and in training. She said there should be a high quality GUM/family planning service for each CHP and investment in regional clinical networks.

Challenges

Three discussion groups representing the three 'regions' of Scotland - essentially the West, the North and the East/South - looked at the challenges ahead. There was common ground in all the groups although some regional and local issues were also identified.

The main challenges were similar to those expressed in the presentations.These included capacity, recruitment and retention, staff training, poor premises and a perceived lack of status of both family planning and GUM services.

There were fears about raising patient expectations when services were already struggling to meet existing demands.
Concerns were also expressed about the tight timescale (of six weeks) to submit plans and around the lack of guidance about what should be in these plans.

Some said the fact that funding had only been announced for three years made it difficult to plan ahead and could be a barrier to appointing new staff, for example.

There were also concerns about where these new staff would come from - Scotland is already short of nurses and doctors. The North group, which included the Highlands and Islands, raised particular issues around geography and access to services, particularly in rural areas and island communities.

There was a sense that some clinicians felt ill-equipped to engage in the planning process - some did not know how to link in with their board's planners.

There was also uncertainty about whether the plans should be regional or local and whether they were actual 'bids' for cash.

The main perceived problems can be summed up under the headings of money, capacity, leadership, facilities, premises, workforce issues including recruitment and retention and training and a fear that there would not be enough support at board level to achieve the aims of the strategy.

There were also concerns about poor IT facilities and a lack of data collection and access to laboratory services.
There were also questions about how the money would be divided. Using Arbuthnott mechanisms could leave the smaller boards with very small amounts of money.

Concerns were also raised about the different situations across the country - some boards were starting from a better point than others.

Solutions

In the afternoon discussion session, the groups were asked to consider the type of support they would like from the centre and to come up with ideas about how they would like to see the process move forward.

Again similar issues were raised by each regional group, although there were notable differences between how individuals saw the way forward.

Suggestions from the group ranged from no further guidance required to more detailed guidance relating to content of plans and clarity over funding

In the North group in particular there was discussion about whether the NHS boards should join up and create a joint plan and essentially pool their budget. They decided that local plans, with regional sign-off, would be the way forward.
Differences in clinician attitudes were also discussed. In remote and rural areas, for example, GPs are more likely to want to keep their FP/GUM skills up because their patients had less easy access to specialist services.

There was support generally for a managed clinical network approach.

There was a clear desire to ensure that NHS Boards recognised the importance of the strategy and that the additional money was for use in developing sexual health services.

There was also discussion around integration of GUM and FP services. The East/South group said that while co-location of services was not necessary, GUM and FP clinicians should be in the same managerial structure.

There was a general feeling that 31 March 2005 was much too tight a timescale to come up with plans and to get NHS board sign off, let alone buy in from other stakeholders.

All regions felt that a further letter from the Scottish Executive to NHS board chief executives stressing the importance of the issue would be helpful.

Way forward

Prof Donnelly said he had taken on board the points made from the floor and stressed again that he wanted to work with the clinicians and others to take the strategy forward.

He acknowledged that the timescale was tight but said it was important both to maintain the momentum and to make it possible to send out the money which would be available at the start of the new financial year in April 2005.
He said that while it was not a bidding process, it was essential that SEHD had clear costed proposals for spending this money prior to disbursement.

He took on board the idea of a 'middle way' - that boards would submit plans containing their first steps and immediate priorities which would allow some money to be released. Boards could then submit more detailed plans with approval from other local agencies within six months.

Prof Donnelly was struck by the amount of enthusiasm about taking forward the action plan and strategy although he accepted that opportunities could also be intimidating. Above all he stressed that there was no prescribed way ahead and he wanted the clinicians to co-direct the process.

Key action points

• The Executive's Health Department will write out to NHS board chief executives. The letter will underline the importance of implementing the strategy, stressing that the majority of money should be spent on frontline services and ask them to submit plans by 31 March so that money can be released. It will also request confirmation of the appointment of an executive director and lead clinician to take the process forward locally and to free up time to allow the plans to be drawn up.
• Initial plans should be submitted by March 31 2005. These should be submitted by each NHS board with input from regional planning teams. They should contain, at minimum, the names of the lead clinician and executive director.
• Each board should submit a further plan by September 30 2005 which gives more detail, describes progress which has already been made. This plan should be shared with other appropriate agencies

Please note that subsequent to the meeting, to assist this process, a pro forma has been developed and is attached for information. Details relating to submission of plans, including the pro forma were sent in a letter to Chief Executives of NHS Boards, copy attached. This confirms arrangements and highlights the key issues raised on February 16, including partnership working, time scales and outcomes.