Island Communities Impact Assessment - Forensic Medical Services (Victims of Sexual Offences)(Scotland) Bill - November 2019
1. Although it is not yet a statutory requirement, the Scottish Government committed to conducting an Island Communities Impact Assessment ("ICIA") for the Forensic Medical Services Victims of Sexual Offences) (Scotland) Bill ("the Bill") as will be required for certain policies by the Islands (Scotland) Act 2018 ("the 2018 Act") once in force. This reflects the importance Scottish Ministers place on ensuring policies are responsive to the specific needs and challenges of Scotland's island and rural communities.
2. This report has been developed in the spirit of the 2018 Act, ensuring that the specific perspectives and concerns of those who live in island and rural communities have been taken into account.
3. The policy background to the Bill and further information about the role of the Chief Medical Officer for Scotland Rape and Sexual Assault Taskforce (CMO Taskforce), is fully described in the Policy Memorandum published on the Scottish Parliament's website.
4. The Bill will place a statutory duty on all territorial health boards in Scotland to provide forensic medical services for victims of rape or sexual assault and will ensure that an individual's holistic healthcare needs are paramount. The Bill will also introduce the statutory framework for health boards to retain samples from a forensic medical examination (which may support any future criminal investigation or prosecution), even if a victim does not wish to report the incident to the police or are undecided about doing so. This is known as 'self-referral'. Together, the provisions of the Bill will underpin the ongoing work of the CMO Taskforce.
5. How these services should be delivered by health boards is set out in the Healthcare Improvement Scotland (HIS) Standards. These were published in December 2017 to ensure consistency in approach to healthcare and forensic medical services for anyone who has experienced rape, sexual assault or child sexual abuse. The standards set the same high level of care for everyone, regardless of the geographical location or an individual's personal circumstances or age. To support implementation and monitoring of the 2017 standards, a set of interim indicators were published in December 2018 and piloted to ensure they provide meaningful data to help inform the continuous improvement of services. The results of the pilot have been used to develop the final indicators which are out for consultation until 19 December 2019. The finalised indicators are expected to be published in February 2020.
6. The Scottish Government has committed £8.5 million over 3 years (2017/18 to 2020/21) to support health boards to imbed the HIS Standards in line with the CMO Taskforce vision and agreed service model (coordinated, multi-agency services delivered as close as possible to the point of need, supported by regional centres of expertise).
Impact of the Bill on island communities
7. The provisions in the Bill will apply equally to all communities across Scotland. This means that a victim of a sexual offence in rural or island communities will have the same legal rights to access NHS forensic medical services, as those in urban and mainland areas, irrespective of whether a police report has been made. The importance of ensuring equitable access to these services was a prevailing theme in responses to the Bill consultation, with 32 out of 53 respondents commenting on the challenges and opportunities that this presents. Chapter 6 of the consultation analysis paper describes the consultation responses sent to the Scottish Government on islands impacts https://www.gov.scot/publications/analysis-responses-equally-safe-consultation-legislation-improve-forensic-medical-services-victims-rape-sexual-assault/pages/7/.
8. The Bill will also underpin intra health board co-operation in the delivery of their statutory duties. This will be supported by the national leadership, guidance and investment provided by the CMO Taskforce.
9. It is recognised, that there is no one size fits all solution to delivering low volume healthcare services in rural and island communities and that each health board may need to adopt a slightly different approach in response to local need and circumstance. However, each island health board is already making good progress towards the delivery of the HIS standards and quality indicators which aim to ensure consistency in the quality of care and support provided.
10. As all of the territorial health boards in Scotland are already working to deliver these standards, the main impact of the Bill will be in relation to the introduction of a national model of self-referral. As set out in the financial memorandum, that may mean a small, incremental increase in demand for forensic medical services in each island health board. A new sub group of the CMO Taskforce will produce national guidance to provide clarity about how this aspect of the service should be delivered in line with the provisions of the Bill.
Scottish Government support for island health boards to deliver healthcare and forensic medical examination services for victims of sexual crime
11. Prior to the creation of the CMO Taskforce adult victims of rape or sexual assault in Orkney and Shetland were often required to travel to the mainland for a forensic medical examination (NHS Western Isles were already providing this service). An early priority for the Taskforce was therefore to support NHS Shetland and NHS Orkney to develop sustainable on-island services so that adult victims of sexual crime no longer need to travel for this purpose. There may be extenuating circumstances when travel may still be required, if for example, a doctor is not available for any reason or if a victim chooses to leave the island for reasons of anonymity.
12. Each health board in Scotland has a senior nominated lead responsible for working collaboratively with the CMO Taskforce and their multi-agency partners to develop and implement costed local improvement plans in line with the HIS Standards and the agreed service model. On this basis, Taskforce funding has been provided to each island health board to enhance existing or to create new healthcare facilities, to procure essential clinical equipment and to help build the capacity and capability of their local workforce.
13. To help ensure an appropriately trained and competent workforce across Scotland, the CMO Taskforce funded NHS Education Scotland (NES) to revise the training for staff to make it more portable, including for remote locations. NHS Orkney and NHS Shetland, together with their multi-agency partners took part in a pilot of this training in 2017. Completion of this specific training, which was designed to incorporate the principle of trauma informed care, is a requirement for all doctors who are involved in the delivery of forensic medical examinations. The training materials are available online, so that staff can access them at any time.
14. A forensic support network provides peer support, education and training for staff in the North Region of Scotland in recognition of the fact that the volume of cases they may see per annum may be quite low. NES is also funded to deliver training in the North given the difficulty of attending training in the central belt.
15. Strong intra-board cooperation also means that if a doctor is not available on an island for any reason, the health board will endeavour to make arrangements for a doctor from one of the mainland boards to travel to the victim to carry out the examination. The experienced teams in NHS Grampian and Archway in Glasgow, are also available to provide telephone advice and support to doctors in the island boards if required.
16. It is recognised that a multi-disciplinary approach is vital to ensuring the long term sustainability of these services, particularly in rural and island locations. As such, an expert group was established under the remit of the CMO Taskforce to develop the role of forensic nurse examiners who can undertake a forensic medical examination and give evidence in court. Considerable progress has been made in this regard and work is now underway to take the first steps towards a multi-disciplinary workforce model in Scotland.
17. Since 2016, the Scottish Government has provided annual funding to recruit an advocacy support worker in the rape crisis centres in Western Isles, Orkney and Shetland. The presence of rape crisis centres on the islands has enhanced direct engagement with island communities on the unique challenges they face and helped victims to overcome the perceived barriers to reporting rape or sexual assault. The Scottish Centre for Crime and Justice Research published an evaluation of this funding which highlighted the range of support provided by rape crisis advocacy workers. The most common was emotional support (52%), followed by provision of advice on criminal justice matters (36%), including the decision about whether to report to the police (22%). Support not relating to the criminal justice process was also provided, including information about health, housing and welfare (19%).
Children and Young People
18. Further information about the impact on children and young people is provided in the Child Rights and Wellbeing Impact Assessment (CRWIA) accompanying the Bill.
19. For reasons explored in the CRWIA, the Bill provides that self-referral is not available to persons under 16. More generally, forensic medical examination is not relevant to many victims of child sexual abuse because the offending is often not disclosed within the 7 day DNA capture window. Access to healthcare and support for recovery will of course be vital irrespective of when child sexual abuse is disclosed to health boards.
20. In line with nationally agreed standards, if a forensic medical examination of a child or young person under 16 (or under 18 with a vulnerability) is required, this must be carried out jointly by an appropriately trained paediatrician and a sexual offence examiner. Clinicians involved in the care of a child who has been sexually abused, together with multi-agency partners, will determine the most appropriate time and place to carry out a forensic medical examination (if that is deemed necessary in the circumstances).
21. In remote and rural communities, if there are no paediatricians available locally, the child or young person may need to travel to an age appropriate setting. In these circumstances, there may also be other factors that would need to be considered, such as access to complementary healthcare or play specialists needed to support the child or young person as well as their parent or carer, which may be more readily available on the mainland. If travel is required, a specific, child centred pathway and appropriate arrangements will be put in place to minimise any unnecessary trauma. For example, arrangements are in place with the Scottish Ambulance Service to consider requests to provide air assets for a flight to the mainland rather than using commercial transport.
22. This model of care is in line with access to other small volume, specialist services for remote and rural areas of Scotland where travel is required for appropriate interventions, with other care being delivered locally.
23. An expert group has been set up under the remit of the CMO Taskforce to look at how improvements can be made to existing services for children and young people, including access to therapeutic care and support. As part of this work, the group has undertaken to scope and appraise different options for the safe and sustainable provision of child centred examination services in remote and island locations and to provide an evidence based recommendation for the CMO Taskforce. This work will conclude by early Spring 2020
24. In order to ensure consistency in practice across Scotland, a clinical pathway for children and young people who have experienced sexual abuse has been consulted on and the responses are currently being analysed. Particular consideration is being given to any enhancements to the pathway which may be needed in the context of rural and island services. This pathway, which recognises the importance of a multi-agency approach to the health, wellbeing and safeguarding of children and young people, will be finalised and published by summer 2020.
25. Variations in Urban, Urban/Rural and Island costings have been considered and costed during the development of the Bill. Further information on this is provided in the Financial Memorandum accompanying the Bill.
26. The Bill imposes the same statutory duties on all health boards to provide an examination service and a retention service. The Chief Medical Officer for Scotland has met with all health board Chief Executives to set out a number of key asks, (including preparing for the Bill and a national model of self-referral) and they have all committed to doing this.
27. As set out above, each island health board has already demonstrated a strong commitment to the establishment and continuous improvement of their local service. This will provide a solid foundation on which to build a local self-referral service when the provisions of the Bill are implemented.