Publication - Consultation analysis

Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis

An analysis of the responses to the consultation on the draft clinical pathway for healthcare professionals working to support adults who present having experienced rape or sexual assault.

Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis
Section 3: Follow up care and mental health

Section 3: Follow up care and mental health

Consultation comment Project group response
249 Not enough emphasis on flexibility and choice The principles of trauma informed care include elements of flexibility, choice, making people feel safe and empowered. Section 6 of the revised pathway emphasises flexibility and choice, and these are also mentioned throughout.
250 The scope and responsibility for this task would benefit from being clearer. Who will take responsibility to organise the appointments for them? Would be helpful to specify what type of appointments – just follow up health? / or trauma support? / or housing? The implementation of the pathway is for local determination. All NHS Board Local Improvement Plans have identified the need for care coordination to support the delivery of the clinical pathway. Scottish Government has provided funding to engage nurse coordinators to fulfil this role.
251 What does “Harmful” coping strategy mean? What is safe for one person may be harmful to another. How will this disclosure impact on a service user’s medical notes? In this context the word 'harmful' needs to be assessed on an individual basis. In a general sense, this refers to coping strategies which may cause further physical, emotional or mental harm.
252 What is the minimum standard / essential information that they should receive? The Clinical Pathways Subgroup agree that this is an important question, although consider the detail of the support information given is out of scope of a clinical pathway. Work is ongoing to review and update current guidance materials available for people who have experienced rape and sexual assault. This feedback will be taken on board when further work is carried out on future guidance.
The Clinical Pathways Subgroup have developed an information leaflet to provide additional information on a forensic medical examination, which can be given to people who disclose rape and sexual assault and who choose to have a forensic medical examination.
253 We are unclear about the psychosocial needs assessment with reference to what this involves and who carries this out. This is usually carried out by the clinician involved in care of the individual. This also may be done in combination with others depending on the individual’s circumstances.
254 It would be hugely beneficial if there was a support worker who took responsibility for patients’ care, separate from the clinician carrying out the forensic exam. This would enable more trust, choice and improve long term wellbeing and criminal justice outcomes by ensuring patient is supported appropriately through the initial information gathering process, forensic examination and given relevant follow up care The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
255 The guidance that there should be an anonymous feedback mechanism in place (7.6.4 P46) is hugely valuable. However it is difficult to implement this anonymously due to the small number of patients seen. The feedback form should not be long or complicated but it should ask well thought out questions in order to get an accurate picture of the care patients receive. The idea the feedback form should be given at a follow up appointment is very worrying as this automatically excludes patients who felt unable to return – arguably those who will give the most valuable feedback are those who have had the worst experience of the service. There should be clear signs informing all patients of the feedback mechanism in all areas e.g. waiting room, examination room and any other areas. There should be forms available for patients to help themselves too and a patient should be given one as a standard procedure regardless of how the visit was concluded, and patients who are expressing upset and frustration should be particularly encouraged to make use of these forms. However for the feedback mechanism to be valuable, the feedback has to be taken into account and adjusted accordingly to provide the highest standard of care The Healthcare Improvement Scotland Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse, Standard 1 (leadership and governance) notes that people should be informed about what to do if they wish to make a complaint or provide feedback about the service or facilities they have experienced. It is the responsibility for individual NHS Boards to meet this standard.
256 The Pathway instructs that a support worker should make contact with the patient in the days following presentation. (7.2.2 P34). It would be more person centered if this support worker was known to the patient from their initial consultation. It would be off enormous benefit if this support worker was the main point of contact for the patient and took on the role of assessing risks, and arranging any referrals and follow up support. It would be beneficial as it would reduce the forensic clinician’s responsibilities to duties associated with forensics and clinical treatment. This would benefit the patient as they would be able to build a relationship with a member of staff that is purely there to support them, separate from the member of staff carrying out difficult forensic examination. The support worker would be responsible for decisions regarding patients wellbeing and supporting patient to make decisions regarding which parts of the examination they wish to undergo The Clinical Pathways Subgroup agree with the principles of this comment. Delivery of the pathway, including care coordination and models of ongoing support, is for local determination.
257 It is not clear about who would do the psychosocial needs assessment. Is this still the initial health care worker, or a further option? In the box at the bottom it references a number of agencies, but Rape Crisis, the only specialist national organisation working with survivors, is not listed amongst them, albeit listed later in the document. Health professionals can be wary of making referrals out with the NHS so without overt naming are unlikely to do so. The introduction to the document talks about multiagency and partnership, so this needs to be reflected in the pathway. Given the document is aimed at being used as required it may be when someone needs it they do not have time to read the whole document and will only refer to crucial key information so this should be listed here. Also it states ‘offer a choice of services’. This could mean give a leaflet with a number of organisations, but if many services have lengthy waiting lists this is not really a choice.
Given p44 references immediately available there needs to be a review locally of what the capacity is to respond timeously.
The Clinical Pathways Subgroup expects that there would be multi-agency groups in operation locally and that a partnership approach is taken across all sectors. NHS Board Leads will lead discussion within their multi-agency groups to determine how best to progress these issues within their local area.
258 This section refers to safety throughout which is confusing as it is often unclear if it means practical safety or emotional safety. Reading it the sense I get is it mainly refers to emotional safety, perhaps it would be beneficial to use separate terms of “safety” and “wellbeing” to allow the reader to distinguish between the two separate concepts. Also there no advice given on what should be done if the patient is at risk by returning home, unless it is as a result of domestic violence, ignorant to the fact the a patient may be at risk at home from a perpetrator that isn’t a partner Training on gender-based violence is provided to forensic medical examiners and those working in professional services. The Clinical Pathways Subgroup acknowledges that the perpetrator is not always the partner.
259 This section involves the patient being asked a large number of questions, which are likely to be emotionally challenging to answer. Rather than using a series of insensitive yes/no questions to determine risks, perhaps the psychosocial needs assessment would be more effective if the member of staff used a human being approach and spoke to the patient as a person, in a natural conversational manner, in order to determine the psychosocial needs of the patient. This supports the need for traumatised individuals building trusting relationships The Clinical Pathways Subgroup agreed that connecting with people on a human level is essential to delivering the pathway in a person-centred way. As part of this, clinicians are trained to adapt their language, offer choice and be flexible in their approach.
260 There should be further clarity about the range of advocacy services available, as not all victims will want to use Rape Crisis. The clinical pathway highlights that advocacy support should be offered. Details of local advocacy services are out of scope of a national clinical pathway, and will be for NHS Board Nominated Leads to determine locally.
261 Some statutory agencies may require additional training to enable them to take on this specialist follow-up role and local areas should be asked to consider assessing any additional support that may be required. The national preferred service model recognises the need for everyone involved in providing treatment, care and support to those with lived experience to have the relevant skills and competencies, backed by accredited training where appropriate. Specific to the role of forensic medical examiners and nurse chaperones relevant training is being provided by NHS Education for Scotland. For those professionals providing on-going treatment and care at any part of the clinical pathway journey, all registered clinicians are personally accountable for working within their scope of practice which requires them to demonstrate that they have the relevant skills, competencies and experience to deliver services to the highest standards. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
262 How is this considered if an adult with incapacity? The Clinical Pathways Subgroup have updated the section of the pathway relating to capacity following discussions with stakeholders.
263 But it is not detailed enough about the patient choices and where the follow up care is to be delivered Implementation of the clinical pathway is the responsibility of NHS Boards and local partnerships. Each NHS Board has a nominated lead to ensure services develop to meet HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults and implement the pathway.
264 There is a plan in our health board area to have a coordinator based within the new forensic unit however, this has been committed to only for a year, and additionally it will be a signposting service in the main. It doesn't address the need for trauma informed services in our area. Our centre is only just reopened a waiting list and without significant sustainable funding investments in the service, this will be a situation that is likely to be ongoing. Implementation of the clinical pathway is the responsibility of NHS Boards and local partnerships.
265 There is also no attempt to understand and respond to patients who present multiple times as a result of experiencing on-going abuse The Clinical Pathways Subgroup agrees that this is something that needs to be explored further; however, this is for local partnerships to address with referrals to relevant support services in their area.
266 The person providing the healthcare is the forensic examiner, their role is an agent of the justice process including making judgement presented to the court. It is not person centered for this person to also be assigned the role of assessing psycho social risks and providing support. The Clinical Pathways Subgroup takes the view that the sexual offences examiner is not an agent of the justice process, but offers clinical assessment and treatment and, in doing that, obtains evidence that may be used in the justice process.
267 Service users where concerned that the only consultation came at the end of the process. Professional needs came first. The CMO Taskforce was established on the basis of feedback from survivors and the Her Majesty's Inspectorate of Constabulary in Scotland report. There is also a reference group on the Taskforce, whose role is to provide feedback and views of survivors and a member of this group is a member of the Children and Young Persons Subgroup. The options appraisal report also included further representation.
268 Focusing on patients drug/alcohol use, self-harm, mental health etc. doesn’t show understanding of trauma as these are commonly affected by trauma The Clinical Pathways Subgroup agrees that the issues of substance use and self-harm may be a response to trauma. The Clinical Pathways Subgroup does not think that the emphasis on these issues is disproportionate; they may be relevant to the clinical history, the forensic examination and to the ongoing support required by the individual.
269 Consideration would need to be given to building and sustaining strong multi-agency partnerships. Where this exists we feel the follow up care component is person-centred if this approach to working is embedded. Noted.
270 I fear this could do significant damage to a victim of sexual abuse particularly those with children and it seems more like Introducing GIRFC through the back door
than anything else an outlawed apparatus struck down by the UK Supreme Court very recently in fact so I would recommend a legal challenge by interested
Groups on this measure to certain parts of it if it should be attempted to be implemented hear in Scotland.

While any reasonable person would agree that no child should be subjected to physical or sexual harm this follow up recommendation has the potential to punish
adult sex abuse victims for being sex abuse victims themselves through no fault of their own by recommending the removal of their child from them. The point alluded to that a child could be removed as it could be a victim to abuse even if they have not been a victim of abuse or witnessed abuse in order to reduce some sort of other alleged abuse contrived by an outside unaffected civil servant is an absolute hilarious and makes none sense it either is a victim or not I find this more of an excuse to remove a child on a whim than to protect them. The public are not stupid.

There is also the danger that those that suffer from disabilities such as mental illnesses due to genetics or trauma of being victims could be targeted prejudicially for removal of their children from their homes. Those that cannot provide fully emotionally or materially due to suffering from being a victim, having a disability or due to
poverty could also be unduly selected by the civil service to have their children removed via a vague accusation of neglect of essential material and
emotional needs being given to the child adding to alleged suffering - No.
Noted.
271 As mentioned in our responses to Section 1, Question 2 and Section 2, Question 2, although the consultation paper refers to the longer-term consequences of sexual assault and rape, the clinical pathway focuses almost exclusively on management of disclosure of very recent trauma. Although it refers to The National Trauma Training Framework, the pathway lacks detail regarding people who delay disclosure, which is more frequently the presentation overall and also in Mental Health/Addictions services where the initial presentation is usually with the long-term consequences of trauma. Noted - further information has been added to the pathway to make it clear that the primary purpose of the pathway is meet healthcare needs following the disclosure of acute cases of sexual assault or rape. Information has also been included in the introduction about delayed disclosure and appropriate health care / sources of support.
272 Provided staff well-trained, there is plenty of time given; and environment within which examination occurs is seen as safe Noted.
273 The gender of the support worker should also be considered and not limited to that of the examiner. The national model and the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults recognise the need for person-centred care which includes the individual directing their own treatment and support plan and choices of the sex of staff involved in providing services.
274 Respondents were surprised that little reference was made to trauma in follow up care. Respondents had expected guidance on how to assess patient’s trauma needs. The International Trauma Questionnaire was suggested as an appropriate tool. Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce
strategy. Reference to the international Trauma Questionnaire will be added to the pathway as a resource for professionals.
275 But it would be beneficial to have a summary of all follow up planned (appointments/ dates, times etc.) recorded and given to patient. A section has been added to the national form which can be given to the person following the examination, which will include information on follow up appointments etc.
276 But, again be mindful that service provision across Scotland is NOT uniform and there will be gaps and delays in remote and rural areas. The clinical pathway document outlines a national response to people who have experienced rape and sexual assault. Implementation of the pathway and wider service design is for local determination.
277 Appointments and information regarding other services accessed at a later date, for example sexual health screening or pregnancy testing, are not covered. Section 9.1 of the pathway covers follow up care, which includes sexual health screening, pregnancy testing, psychosocial assessment and support and ongoing trauma support.
278 Third sector - especially important to consider the impact on trauma in client attending and or engaging with services. So that the client is not discharged when they fail to engage initially... this area needs to be stressed to avoid multi agency services discharging client too soon The Clinical Pathways Subgroup note that this is one of the principles of trauma-informed care which underpins the document.
279 “They should be directed to other services that could support their needs”
Directed - This possibly contradicts the previous comment about people not having to book and organise follow up appointments -should contact / appointments be made for them?
Wording has been amended in the revised pathway.
The previous Chief Medical Officer asked NHS Board Chief Executives to ensure there is a single point of contact to provide support with the coordination of ongoing care and support for victims.
280 “Healthcare professionals should make sure that the person has somewhere safe to go home to”.– The scope and responsibility for this task would benefit from being clearer. How thorough is this commitment? – will a health care professionals make arrangements for a victim or contact housing on their behalf? Wording has been amended in the revised pathway to make it clearer that this is a multi-agency responsibility.
281 “A plan should be made” – Would be helpful to clarify the purpose and scope of the plan. What will this plan be used for? for the victims use to create a sense of safety? or is this a professional plan with timescales and assigned tasks? Wording has been amended to make it clear that this is a professional plan made jointly with the individual, including timescales.
282 Insufficient resources to support follow-up care delivered timeously across all parts of Scotland, in the north Highlands there is no immediate support from Rape Crisis depend on GP, person travelling or telephone support. Not equitable. Priority should be given to immediate provision one to one support and children. The delivery of the clinical pathway at a local level is the responsibility of NHS Board Nominated Leads and relevant local partnerships.
283 There is a need to improve services for male victims of Childhood sexual abuse or sexual assault. While the consultation paper does acknowledge that male survivors have particular difficulty disclosing that they have been victims, there are no suggestions as to how male survivors can be supported to discuss their experiences. The Clinical Pathways Subgroup agrees with this comment. The vision of the Chief Medical Officer's Taskforce is for consistent, person-centred, trauma informed health care and forensic medical services and access to recovery, for anyone who has experienced rape or sexual assault in Scotland. The Scottish Government made clear through its Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill that there must be equal access to services and support for victims who are men and boys.
284 More emphasis on psychological component of harm --perhaps access to supporter at the time? The clinical pathway document outlines a national response to people who have experienced rape and sexual assault. Implementation of the pathway, including referrals to relevant support services, is for local determination.
285 The only note of caution would be in terms of follow up care and support - we know we have huge waiting lists and pressure on third sector specialist service as well as psychology services so this needs to be considered in terms of the pathway. All local improvement plans take account of the need to develop capacity in services such as mental health in order to meet demand and implement the pathway. Scottish Government has provided additional funding to NHS Boards and local Health and Social Care Partnerships to improve access to Mental Health Services. The Taskforce has also provided funding to improve through care services.
286 The victim should be offered a scheduled phone call in between leaving after examination and coming back in. If a victim has come straight into the process after being raped (not a delay in reporting) then many times they have not had the chance to talk to family or friends. The prospect of going home after such a traumatic experience is very daunting and lonely. Advice on Rape Crisis Helpline should be provided at a very minimum. This aspect has been incorporated into the revised pathway.
287 See comments re 1.4 - (repeated here) It is not clear how the trauma support is established above and who is assisting the survivor to explore their options and choices. It could be interpreted that ‘trauma support established’ is in the manner of the health care worker such as the GP, and not something more robust and meaningful. Rape Crisis support & advocacy staff would be ideal for providing this, and the evidence noted in the evaluation below highlights how vital having this early access to specialist support and information is in navigating the justice process. The Rape Crisis national helpline, which is currently open 6pm to midnight provides timely access to this support and information and could also play a key role but is limited currently to 6pm to midnight. For both the Nation Advocacy Project and the national helpline there are some issues of capacity and additional funding would be required to ensure timeous specialist access.
Engaging with the criminal justice process can be a daunting one and having early access to support & advocacy can be ‘life changing’ (according to the evaluation of the Rape Crisis National Advocacy Project’. https://www.sccjr.ac.uk/publications/evaluation-of-the-rape-crisis-scotland-national-advocacy-project-final-report-2018/) Having the support & advocacy option highlighted prior to Police engagement would enable informed choice about engagement.

It is not clear about who would do the psychosocial needs assessment. Is this still the initial health care worker, or a further option? In the box at the bottom it references a number of agencies, but Rape Crisis, the only specialist national organisation working with survivors, is not listed amongst them, albeit listed later in the document. Health professionals can be wary of making referrals out with the NHS so without overt naming are unlikely to do so. The introduction to the document talks about multiagency and partnership, so this needs to be reflected in the pathway. Given the document is aimed at being used as required it may be when someone needs it they do not have time to read the whole document and will only refer to crucial key information so this should be listed here. Also it states ‘offer a choice of services’. This could mean give a leaflet with a number of organisations, but if many services have lengthy waiting lists this is not really a choice. Given p44 references immediately available there needs to be a review locally of what the capacity is to respond timeously.
The Clinical Pathways subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
288 Within the follow up component there is no reference to those who may be subjected to human trafficking; it would be helpful to include guidance on how the service should respond if they identify victims of human trafficking to ensure they receive appropriate care. Guidance should also include the responsibility for referral to a first responder and then to the National Referral Mechanism. Wording amended - human trafficking has been referenced in the revised pathway.
289 The Guidance is “light” in relation to direction for the local implementation of the agreed Clinical Pathway; who is responsible for the implementation and how is it quality assured?
The Guidance would benefit from a suggested “referral pathway” as part of the Clinical Pathway, to be implemented in principle at local level
Training and workforce development in the Guidance needs to be more explicit, to support the workforce at local level to be clear about their role and the impact of their response.
There needs to be a stronger link with domestic abuse services at local level re sexual violence within intimate relationships (over 50% of rapes are within the context of a relationship). The Guidance would strengthen the referral routes and working partnerships if services were guided to consider referral to sexual violence services and encouraging survivors to report.
The Clinical Pathways Subgroup agrees with the principle of this comment; however, implementing the pathway is out of the scope of this document. Details on implementing the national clinical pathway at a local level, including referral pathways and training will be addressed by a national sexual assault service specification. This is being developed following on from the options appraisal report 'Honouring the Lived Experience: Rape and Sexual Assault Victims Taskforce' which was carried out in June 2018.
Further information has been added to the pathway around links to domestic abuse services.
290 As a former SARC support worker, FPA's clinical lead was the patients advocate throughout the forensic examination process, as well as throughout the initial discussion. It be may be beneficial to add the role of the SARC support worker in this section. NHS Board Nominated Leads will lead discussion within their multi-agency groups to determine how best to provide individual support throughout the pathway within their local area.
291 There is a lack of clarity and details of who, when, where and who does what. The clinical pathway document outlines a national response to people who have experienced rape and sexual assault. Implementation of the pathway and wider service design is for local determination.
292 Availability of alternative health services are not really covered. The national preferred service model recognises the need for everyone involved in providing treatment, care and support to those with lived experience to have the relevant skills and competencies, backed by accredited training where appropriate. Specific to the role of forensic medical examiners and nurse chaperones relevant training is being provided by NHS Education for Scotland. For those professionals providing on-going treatment and care at any part of the clinical pathway journey all registered clinicians are personally accountable for working within their scope of practice which requires them to demonstrate that they have the relevant skills, competencies and experience to deliver services to the highest standards.
The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
293 Generally smooth where there is a service Noted.
294 Unsure --depends how locally configured and on how well local system works Noted.
295 However, in most areas, the ways of co-ordinating this will have to be discussed and agreed. Noted.
296 From day one, the victim needs a point of contact that they can ask questions to. I was lucky to have my SOLO from day one of reporting the crime to the day my case went to the High Court. Even when my case was passed to the PF my SOLO was still supporting me. Noted – the role of the SOLO remains a very important part of the pathway.
297 This will be very much dependent on how this is put into practice. Building relationships between key partners, which is already underway in a number of health board areas to forge constructive pathways between statutory and third sector services is vital, as is adequate resourcing to enable services to be able to effectively and timeously respond. Identifying who coordinates this will be key. The Clinical Pathways Subgroup agrees with this comment. The benefits of collaborative working across all sectors and agencies are recognised within the pathway. The CMO Taskforce promotes a multi-agency approach with health services co-located with other agencies and partners to help deliver a smooth pathway of care.
298 Again this will depend on systems in place locally to facilitate speedy and smooth transition Partnership working will be facilitated through the multi-agency groups established to lead on this improvement work in all NHS Board areas. This is for local determination, and is therefore not in the scope of a national clinical pathway.
299 However, this will be contingent on constructive local relationships / pathways between all the key partners involved. Noted.
300 It will depend hugely on how this pathway is put into practice and who coordinates the pathway. Strong and effective partnerships between statutory and voluntary sector organisations is key to making this an effective response for survivors of sexual violence. There is work being undertaken in our area already however, additional resources will be required in our rural area to put the pathway into practice. The Clinical Pathways Subgroup agrees with this comment. The need for multi-agency partnerships and collaborative working is strongly emphasised within the pathway. Implementation of the pathway is for local determination, and is therefore not in the scope of the Clinical Pathways Subgroup.
301 I fear however that the government will use such easy transitioning without care for privacy rights of the individual, any trafficking of a victims data should be done only with the written consent of the individual. The Clinical Pathways Subgroup recognise that how an individual’s data is processed is a concern. Data is processed in line with local health board policies and processes.

Contact

Email: CMOtaskforce.secretariat@gov.scot