Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health
Section 4 Providing Better Services
33. Lifelong learning about relationships and sexual health must be complemented by accessible, confidential and appropriate clinical services. Advice, counselling and support are also crucial. This can range from choosing the appropriate method of contraception in line with lifestyle to psychosexual counselling and relationships support, and support for those who have experienced sexual abuse.
34. There are many examples of good and innovative sexual health services across Scotland. However, there are also wide variations in terms of availability, quality and choice and a number of recognised challenges that limit the impact of these services. Confusion, or lack of knowledge about sexual health, or about the range of available services may discourage or delay attendance and result in poor management of preventable sexual ill-health problems.
35. The challenge is to secure a cohesive, seamless approach to clinical services. The fundamental principle should be that every person should have a choice when accessing sexual health services and be able to self refer to all such services. Service provision should be based on the principle of providing services which are as local as possible and as specialised as necessary.
36. The principle is to make best use of resources by providing appropriate levels of care, supported by appropriately trained staff. Therefore, all of these services should be provided by skilled, confident and suitably equipped staff, who are able to respond to the needs of their clients, either directly or by referral to other service providers in accordance with clear protocols and guidelines. These staff will be from a variety of professional disciplines and will be specialised to varying degrees. Boards will, therefore, be expected to invest in an appropriate mix of additional consultants and in the training and employment of General Practitioners with specialist interests as well as specialist nurses. These consultants, GPs and nurses would have an interest in relevant areas, e.g. genitourinary medicine, family planning and community gynaecology. The Executive is keen that these areas of work should be brought together, whenever possible. Service redesign will be required to make best use of both physical premises and human resources, with geographical outreach and extended user-friendly opening becoming the norm. In particular, a greater focus upon rapid access to a primary care centred model of care would be helpful.
37. The attitudes and outlook of staff who deliver services are important for all users and services will be provided with equality, professionalism and respect.
38. Opening times, geographical locations, suitability of premises, and perception of the services by users may limit accessibility, for example, if men feel services are targeted at women or if women do not wish to see a male practitioner. These issues may also affect staff recruitment. Service providers should seek therefore to identify and address barriers to access for their communities, whether attitudinal or physical, actively involving users in this process.
39. Access to services in rural areas raises particular issues which NHS Boards and their partners must address. This is an issue which will also be considered by the National Sexual Health Advisory Committee.
40. The decision of any individual practitioner to opt out of providing specific sexual health services will be respected but, in such circumstances, they should give information on, and refer patients to, accessible alternative services.
41. Individuals need accurate, unbiased information, guidance and services if they are to take responsibility for their own sexual wellbeing. Standardised evidence-based information on sexual health and services, suitable for a range of audiences, including those who are disabled or are not currently accessing services, should be provided through modern accessible methods of communication. Clear information and referral protocols should also be available to staff who will refer patients to services.
CLINICAL STANDARDS AND TARGETS
42. It is important that appropriate clinical standards are developed for dealing with sexually transmitted infections and this will be taken forward by NHS Quality Improvement Scotland.
43. Targets are also important to help monitor service development and ensure that patients get the quick, responsive service they need. It will be an early task of the National Sexual Health Advisory Committee to offer advice on challenging targets that will help deliver key elements of the strategy, against the background of the Executive's drive to further improve health services performance, and reduce waiting times. Boards' assessment of their performance against these targets will be reviewed and published.
44. Confidentiality is a sensitive and delicate issue about which there is often a lack of clarity among service users as well as others with a concern for the welfare of a young person or patient. A key statutory provision in Scotland is the Age of Legal Capacity (Scotland) Act 1991, which confers on any young person, without a lower age limit, the right to give consent to his or her own medical treatment, provided that the clinical judgement of the doctor attending the young person is that the latter is competent to understand the nature and consequences of the treatment. A competent person under 16 is owed the same duty of confidentiality as an adult.
CONTRACEPTION AND TERMINATION
45. The full range of contraceptive methods should be available to patients. If a service provider is unable to offer a particular method, they should facilitate access to alternative readily accessible services. Referral between the various services should promote access to specialist services, where gynaecological side-effects and complications or underlying medical conditions make use of contraception more complex. To help provide protection against sexually transmitted infections as well as unintended pregnancy, condoms should be available and their use encouraged, in addition to other forms of contraception. When providing contraception, including condoms, staff should use the opportunity to promote positive sexual health.
46. Termination of pregnancy is a matter of the greatest sensitivity and the Abortion Act 1967 as amended sets out the statutory framework within which terminations can be conducted. Counselling is a crucial element in any decision on whether or not termination should proceed and it is important that counselling should be non-judgemental and non-directional, with women having access to full information on every option. Professional guidance such as the British Medical Association's ethical guidelines on the law and ethics of abortion and the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on
"The Care of Women Requesting Induced Abortion" should be followed.
47. Access to termination services should be available within the framework of the law, and protocols, drawing on the current RCOG guidelines, should exist in each NHS Board area designed to ensure consistency in service response and practice, while recognising that decisions in particular cases will depend on the specific circumstances.
A nominated Executive Director will appoint a Lead Clinician to integrate sexual health services across each NHS Board area.
Lead Clinicians should ensure there is access to appropriate termination of pregnancy services, and that protocols drawing on the RCOG guidelines are in place to help provide consistency in service provision and practice. Counselling and information should be comprehensive and responsive to any individual needs, again reflecting the RCOG guidelines, and should include the biological facts about the development of the pregnancy and the possible emotional, physical and psychological sequelae of termination and alternative courses of action. While women should be given adequate time to assimilate all the implications, in accordance with the RCOG guidelines, no woman should have to wait longer than 3 weeks from her initial referral to termination.
Lead Clinicians should ensure barriers, including those affecting rural services, that restrict the use of services are identified and addressed, and 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 are reviewed against the values and principles identified in this Strategy and that proposals to address identified deficits are included in each NHS Board's inter-agency sexual health strategy.
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 area should review existing service information, revise and make this available in a range of easy to read formats, including in language appropriate to local population needs.
Lead Clinicians 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 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.
The National Sexual Health and Wellbeing Learning Network, 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 and social care and education staff, taking into account existing guidance.
Lead Clinicians should ensure that local standards on agreed competencies, confidentiality, access to and provision of contraception and termination are developed in line with professional guidance.