The Scottish Government

Commissioners event held in Murrayfield Stadium, Edinburgh, on March 24 2005

Introduction

Implementation of the Scottish Executive's sexual health strategy is now underway. Last month (February 16) clinicians from each of Scotland's 15 NHS boards attended a workshop in Edinburgh to discuss taking the strategy forward. As a result, NHS boards are already working on initial plans for sexual health services, which are due to be submitted to the Scottish Executive by March 31 2005.

The Scottish Executive organised a further workshop on 24 March which aimed to bring together those responsible for delivering the strategy within local authorities, NHS boards and national organisations. Clinicians and the voluntary sector also took part.

The day involved presentations from Scottish Executive health and education department perspectives, from a local authority viewpoint and from the voluntary sector. The 90 or so delegates split off into local or regional groups to discuss challenges, progress so far and the way forward.

Key Points/Summary

• The sexual health strategy and action plan is backed by £15 million of new resources over the next three years - a 50 per cent increase on current provision
• The strategy has political backing at the highest level: the minister for health and community care has taken personal responsibility for the strategy and will chair the national advisory committee on sexual health
• Inter-agency working is key to making the strategy work
• Each local authority must designate a strategic lead for Sexual Health and NHS boards must appoint an executive director to take responsibility for the strategy. NHS boards must also appoint a lead clinician
• It is anticipated that sexual health and progress on the strategy could form part of each NHS board's annual accountability review
• NHS boards should complete initial clinical plans by March 31 2005 and final versions by September 30. Each board area should also submit inter-agency local sexual health strategies by September 30
• Although education and schools are an important part of this, sexual health is also the business of other local authority departments and must be embedded in their policies
• Sexual health must feature in Joint Health Improvement Plans and cover all age groups not just children and young people
• Key challenges include training, a need for clarity around roles and resources, capacity, premises and communication
• The voluntary sector has a great deal to offer, can complement statutory services, have expertise in reaching vulnerable groups and can help implement the strategy
• There will be an on-going dialogue between the Executive and other agencies

Policy Context

The Scottish Executive published its sexual health strategy, Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health in January 2005.

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

Andy Kerr, the Health and Community Care Minister, promised £15 million extra funding over the next three years to implement the strategy - the majority will be used to improve frontline services.

Mr Kerr will chair a National Sexual Health Advisory Committee. He has made it clear to NHS board chairmen and chief executives that he expected to see progress on implementing the strategy and that it could figure in their annual accountability review.

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
• Where possible, sexual health services including family planning and GUM should be integrated.
  

Key recommendations for local authorities include:

• Each local authority will designate a strategic lead for sexual health
• Ensure that Joint Health Improvement Plans address both specific sexual health issues and the wider determinants in the strategy
• Work through the local authority director with responsibility for education and social work services to ensure the delivery of high-quality sex and relationships education in all school settings, for those excluded from school and for other disaffected or vulnerable children.

Presentations

Scottish Executive Perspective

Colin Cook, newly appointed head of the public health division in the Scottish Executive Health Department (SEHD) said sexual health was a key strategic plank of the Executive's overall health improvement strategy.

He said that each board area should have completed local inter-agency agreements on how they would be implementing the sexual health strategy, adding that this event was the start of the process. He stressed that making the strategy work was very important to the Executive and that the political will, backed with new funding, was there to make it happen.

David Pattison, specialist public health advisor in SEHD said publication of the sexual health strategy was a cause for celebration. He said there were challenges around delivering it locally, regionally and nationally but it was important to make sure it did not remain a 'bit of paper' but was something that was workable. It was an important time for sexual health services and the importance of ministerial commitment and buy-in could not be under-estimated.

He outlined the key recommendations, including the formation of a national sexual health advisory committee, which the minister will chair (for other key recommendations see Policy Context section above). He said parents should be actively encouraged to contribute to the process.

He said the inter-agency local sexual health strategies to be submitted by September 30 should include a review of existing services, particularly with regard to accessibility, location and opening times. The needs of older people should not be overlooked and there should be an audit of training needs.

Another key outcome should be that health promotion programmes should be supported by sexual health promotion specialists.

He said people delivering sex and relationship education (such as teachers or school nurses) may have technical skills but might need training to build their confidence in this area.

The extra resources marked a 50 per cent increase in funding but said that the plans should look at current money as well to ensure effective spending.

While the emphasis was on frontline services, he said there was a need for an integrated approach, taking in prevention, education, information, advice and support. Above all he called on the delegates to use the strategy to develop good work. It was an opportunity to 'aspire to positive sexual health and well-being'.

Heather Jones, head of the Pupil Support &Inclusion Division of the Scottish Executive Education Department, stressed that there was close working between her department and colleagues in SEHD on the sexual health strategy and that the role of local authorities and schools was woven in.

She said the Executive wanted to know how the strategy was progressing on the ground and said it had a responsibility to listen to what it was being told.

Ms Jones outlined strategic pillars of the strategy, including promoting respect and responsibility, preventing STIs and unintended pregnancies and providing better services.

She stressed that for teachers, the strategy meant building on what they were already doing - that it was consistent with the McCabe report (on sex and relationship education, published in 2000). It was important for teachers to be equipped properly to look at pupils' needs and deliver education effectively.

She said there should be better cross-agency working and common standards on, for example, confidentiality. She also said there should be multi-agency training. She commended the integrated community school approach and said communication, both inter-agency and with parents and pupils, was key.

She laid out the responsibilities of the different groups involved. Local authorities should designate a strategic lead, makes sure sexual health is part of JHIPs and other strategies, continue to deliver McCabe, provide continuing professional development for staff and support schools in delivering the strategy.

As well as providing services, NHS boards should support schools in delivering the strategy and buy in to joint training. The Scottish Executive should facilitate and co-ordinate delivery and ensure McCabe is rolled out successfully. She mentioned a number of key partners including the Scottish Health Promoting Schools Unit and parents.

Local Authority Perspective

Douglas Hamilton, policy manager with Cosla, said that while schools and education were crucial in delivering the strategy, that was not the whole picture. There had to be a whole-authority approach which took in all the other areas where councils can have an impact on sexual health. These include environmental issues, such as housing and employment and lifestyle factors, such as licensing activity to curtail under-age drinking.

Local authorities have an important role in encouraging attainment and aspiration, which should encourage people to want positive sexual health and wellbeing.

He identified some potential barriers, including a need to clarify roles. Communication was vital, he said, to ensure this was seen as a partnership rather than 'an NHS thing'. He said it was important that it was not seen as an extra layer or additional burden. He also said clarity was needed on the new resources - who would get what and would they all go through the NHS board?

Voluntary Sector Perspective

Hawys Kilday, chief executive of Caledonia Youth (formerly Brook in Scotland) made it clear that the voluntary sector was not in competition with statutory services, but could complement existing services, provide value for money and bridge gaps and tackle existing inequalities.

She said there were many voluntary sector organisations carrying out great work with young people in Scotland.
The voluntary sector's long experience of listening to young people about what they want could also be an invaluable resource, she said.

Ms Kilday outlined some of the USPs (unique selling points) of the voluntary sector, including its skill in building collaborative working relationships, its focus on the disadvantaged and its expertise and innovative practice.
From Caledonia Youth's experience, young people don't only want decent clinical services - they want information, education and counselling services and they want it delivered in confidential, non-judgmental settings.

Tim Street, director of the Family Planning Association (FPA) in Scotland, pointed out that sexual health wasn't just about young people. He said there were good examples of partnership working between the voluntary and statutory sectors. For example, Lanarkshire had involved the voluntary sector right at the beginning of drawing up their sexual health strategy rather than leaving it as a 'bolt on'.

The voluntary sector's skills include listening, information gathering and targeting resources where they were most needed, he said - finding out what 'real people' need. He spoke around the subject of HIV/Aids, pointing out that the voluntary sector had led the way on this issue in the UK. The voluntary sector could act as intermediaries to help people come forward to access services, he added.

Key issues were training, which should be cross-sector and multidisciplinary, he said, adding that voluntary sectors tend to be able to act more quickly than statutory organisations. He said voluntary sector could help deliver on the strategy.

Key Challenges

Workshop sessions were held with small groups of delegates, based largely on NHS board areas. There was also a group made up of voluntary sector organisations and national organisations, including the Scottish Prison Service and NHS Health Scotland (see attendance list in appendix for complete list).

The groups were asked to come up with three key challenges to successful implementation of the strategy.

A number of common themes emerged - indeed, many of the concerns were similar to those voiced in the clinicians event in February.

Many groups identified resources as in issue. Most wanted clarity about how they would be distributed. Some areas were concerned that because NHS boards had appointed executive and clinical leads, while local authorities hadn't, all the money would be used in health services. Others felt that although the minister had said the majority of resources should go to frontline services, the needs of the strategy could not be met without investment in wider prevention and education issues.

One west coast group spoke about the challenge of bringing religious groups, particularly the Roman Catholic Church, on board. Others raised the issue that already some parents were removing their children from sex and relationship education while a small minority were citing this as the reason for deciding to withdraw their children from school and educate them at home.

The group made up of national and voluntary organisations stressed the importance of realising that everyone had values, not necessarily based on religion.

They also believed that lead clinicians should be involving voluntary organisations at an early stage - and felt they should have an opportunity to bid for resources to provide services aimed at implementing the strategy.

The delegates from Lanarkshire raised issues around hard-to-reach and vulnerable groups, such as looked after children and Black & Minority Ethnic groups.

They expressed concern that some premises were not fit for purpose and said there were particular challenges in rural areas.

Tayside raised a number of dilemmas, for example, finding the right balance between clinical services and prevention and between population-wide initiatives and those targeted at particular groups. One delegate also said it was important not to regard parents as the enemy, but acknowledged there were big communication issues.

The group representing the island boards were concerned that their share of funding might not be meaningful if it was allocated using Arbuthnott.

There was also an issue around blood-borne virus funding, which has not yet been announced for the next financial year, causing staffing and planning problems.

The group representing the Borders and Dumfries & Galloway were also concerned about isolated groups, including lesbian, gay and transgender groups.

In Lothian again questions were raised about resources, including the difficulty schools already have in accessing funds for healthy initiatives. One delegate expressed dismay that some schools still have vending machines selling unhealthy food in schools, but another pointed out that schools could ill afford to lose the money such machines generated. We were therefore left in a situation where we could have 'fat kids who practised safe sex or thin kids who didn't', said one delegate.

Highland was concerned about issues around rurality, including the difficulty of accessing confidential services. They were also concerned that the new funding was not explicitly recurring.

Solutions/Way Forward

In the afternoon, the groups split off again. Those representing the North decided to work together in one big group to hammer out common issues and discuss ways they could work in partnership.

Some groups which were further ahead in the planning process used the time to carry out specific pieces of work which they needed to do. For example, Ayrshire and Arran, which had already held two away days on the strategy, used the time to scope a training needs assessment.

The groups came back with ideas on the way forward while some also gave an update on how far they had come.
Ayrshire and Arran said they had already worked on their funding proposal and were planning to recruit someone to carry out a training needs exercise and other projects. In the first year, they planned to concentrate on recruitment, training, IT and capacity-building.

Argyll and Clyde and Greater Glasgow delegates, who had joined up in the individual workshops, said that as they shared some common local authorities, a certain amount of joint working made sense. They said NHS Greater Glasgow had already written to other health boards to see where they could go as a region. They wanted local authorities to identify leads as a priority.

Fife already has a multi-agency sexual health strategy group and is coming to the end of the first three years of its own strategy. Delegates used the time to map out the next six months for the new strategy. Key areas include communication, training and getting buy-in from other agencies. They plan to use the first tranche of new money to look at an integrated sexual health service including GUM, family planning and community gynaecology.

Forth Valley delegates' main point fed back by the group was that the local authority executive lead should represent both children's and adult services. Earlier in the discussion the feeling among some of this group was that now they had the strategy, they just had to sit down and get on with it. One way of making it happen might be to second people with relevant experience - an example of where this had been done successfully was the local drug and action team, one delegate said.

The North delegates want to set up a formal managed clinical network in sexual health across their NHS board areas. They want to co-ordinate training, for example and share some specialist services. An example of a shared post might be a nurse consultant to work across the region.

They want to share best practice and avoid reinventing the wheel. They plan to hold an event in a year's time, specifically looking at the rurality issue.

The National and Voluntary organisations group spoke of inclusion, values and the role and make-up of the advisory committee. They felt all parties involved should be real advocates of the sexual health strategy and that voluntary organisations should have the opportunity to bid for strategy resources. They felt respect and responsibility should be seen in the context of higher human rights values including diversity. Advice should be sought from medical ethics experts.

They felt members of the advisory committee should have knowledge and experience in the sexual health field and not be appointed by virtue of position or their organisation and should have links with inter-agency fora. Research should be commissioned with quick results to identify good practice. They also suggested a post-graduate diploma course in sexual health and said the advisory committee should hold regular media briefings.

Lothian wanted to build on its existing good structures and plans. The delegates felt some of the new resource should be used to facilitate or 'lever' training and there was a plea for local authorities to be able to access resources directly.

Tayside delegates said their local strategy had been finalised and was going to the board in three weeks time. A review and redesign of family planning and GUM had been commissioned and would be finished in July, which would give detail about how money should be spent. Tayside is also developing local implementation groups in each of its three local authority areas.

Joe Logan from the SEHD wrapped up the day, saying this was only the start of the process and there would be ongoing dialogue on the Action plan.

Key Action Points/Important Dates

• By March 31 2005: All NHS boards to submit draft plans to SEHD on how they will be taking forward implementation of the strategy They should contain, at minimum, the names of the lead clinician and executive director, a summary/review of the situation of services locally at the moment, highlighting the most pressing needs. They should address the main action points in the strategy (pages 18 and 19) where appropriate locally. They should also give some idea of how they will approach inter-agency working on sexual health and wellbeing. They should outline the most important first steps and give some idea of costings (within the constraints of their likely share of the money under Arbuthnott). They should also identify key expected outcomes from the plans as well as look at ways of redesigning services (including integration of GUM and FP where appropriate). These measurable outcomes can be as simple as showing that access to services has been improved by, for example, extending opening hours of clinics. The plan should focus on the first year but give broad aims for the following two years.
• By September 30 2005: Each board should submit a further clinical plan which gives more detail and describes progress which has already been made.
• By September 30 2005: Local inter-agency agreements should be submitted to SEHD, covering key areas including training needs across sectors and how the strategy aims and objectives will be met for all age groups. Local authorities will designate a strategic lead for sexual health.