Plenary, 27 Jan 2005

Meeting date: Thursday, January 27, 2005

Official Report 735KB pdf

---

Sexual Health Strategy

The next item of business is a statement by Andy Kerr on "Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health". The minister will take questions at the end of his statement, so there should be no interventions.

I am grateful to Parliament for the opportunity to make this statement.

We have published our strategy on sexual health today and copies are available in the Scottish Parliament information centre. In line with our convention, I made copies available to party leaders earlier today.

It is well known that sexual health in Scotland is poor. Sexually transmitted infections, such as chlamydia, are widespread and increasing. Teenage conceptions are among the highest in western Europe. Between 2002 and 2003, the reported incidence of chlamydia rose by 39 per cent to 9,066 cases among people under 25, and by 36 per cent to 4,160 cases among those over 25. According to the latest available worldwide comparative figures, Scotland's birth rate among those under 20 was 30.6 per 1,000, compared to 6.2 in the Netherlands, 8.1 in Denmark and 9.3 in France. The situation is also worse in some parts of the country than in others.

Improving our sexual health is central to our public health agenda. It is not something to be embarrassed about or to shrug off as someone else's responsibility. It is a problem for all of us—the young and the not so young. Among the over-40s, for example, the incidence of chlamydia and genital herpes doubled in the four years up to 2003.

The answers to improving sexual health lie with us. We can do something about it. Accurate and accessible information will help us to understand where the risks lie and how to prevent them. Access to medical and support services will help to counteract the spread of infection and support the decisions that have to be taken when someone is faced with an unplanned pregnancy. There should be encouragement to take personal responsibility for our own health and the health of those with whom we are having a relationship. Critically, we have to have the confidence to make our own individual and very personal decisions about how we will behave without the stigma or the accusation of not being in with the in crowd.

Sexual health can be a controversial subject. It touches on deeply held views on moral issues, it challenges us on cultural and lifestyle diversity and it tests the strength of our tolerance. Our thinking has been informed by the work of the expert reference group, which we set up to look at those issues and I want to thank it for the important work that it did on our behalf. Not surprisingly, the extensive consultation exercise on its recommendations produced a diversity of strongly held and often opposing views. However, alongside that diversity of opinion there was a strong vein of support for the values of respect and responsibility.

The concepts of respect and responsibility are exemplified in strong and stable relationships, with marriage remaining a key pillar of our national life. Throughout the country there are differing views on the place of marriage as the touchstone of a strong and mature relationship, but the right focus for us in the Scottish Government and in the action that we take to promote sexual health is on the quality of relationships, whatever form they may take.

The strategy and action plan that I have published today are firmly based on the principles of self-respect, respect for others and strong relationships. The strategy recognises the diversity of lifestyles in Scotland today and the range of personal choices that people are making about how to live their lives and who to live them with. However, it is not value free. We support taking the approach of abstinence or choosing to delay sexual activity until a mature, respectful and loving relationship has been established. We support the right of people to have the self-respect and confidence to say no as well as yes and to have that choice respected.

Parents and carers will continue to be consulted on the sex and relationships education programmes and materials that are provided for their children. Young people will be encouraged to build respect for themselves and others, to have the confidence to make the right choices and to delay sexual activity until they are mature enough to have a mutually respectful and loving relationship.

In nursery and the early years of primary school, the emphasis will continue to be on family relationships and friendships and on developing an understanding of how we care for one another. All of us—young adults and older adults—are expected to take responsibility for making our own choices and protecting our health and the health of those with whom we have a relationship. However, making choices is possible only when people have the information that they need to help them to decide. Expecting personal responsibility to be exercised means that we have to give people the means to make their decisions. Therefore, accurate and accessible information is critical. Respecting the right of each individual to have such information and to make their choice must not be limited by whether we like the choice that they make.

Our strategy sets out a coherent framework for improving sexual health in a way that is respectful of children's rights and of parental and personal responsibility. However, above all, the strategy is about improving Scotland's health. Our aim is to prevent sexually transmitted infections and unplanned pregnancy through education, service provision and support; to provide better sexual health services, which are safe, local and appropriate; and to promote respect and responsibility through an approach that recognises cultural and religious diversity, challenges stereotypes and encourages a more open and mature view of sexual relationships.

Our action plan sets out the steps that we will take and those that we expect others to take to provide high-quality and accessible information and services equitably throughout Scotland. The plan does not promote sexual relationships among children; it does not bypass or dismiss the critical role and responsibilities of parents and carers; and it does not diminish or dismiss the importance of stable family relationships. However, the plan promotes the values of self-respect and respect for others; supports those who want to delay sexual activity until they are ready; and recognises the importance of having accurate information, the right skills and the knowledge to understand where the risks lie and how to prevent them. In essence, the message is, "Delay until you're ready, but be safe when you are active."

The best time and place to begin nurturing respect and responsibility are at an early age and in a stable and loving environment. Parents and carers have a major role to play in all aspects of their children's lives. It is they who offer a child stability, security and love. They have a critical role to play in their child's education and it is essential that parents and carers are involved and consulted on the sex and relationships education that is offered to their child.

Schools have a vital contribution to make. We will seek to work with the McCabe report's widely welcomed principles. That report had the agreement of all key stakeholders and it established the framework for the development and delivery of sex and relationships education here in Scotland. It is a framework in which pupils are

"encouraged to appreciate the value of stable family life … the value of commitment in relationships and partnerships"

and to

"understand the importance of … dignity, respect for themselves and the views of others."

Sex and relationships education programmes will take the form of abstinence-plus education, which aims to delay sexual activity, in combination with communication skills development and information about services.

All schools are expected to provide sex and relationships education of a high quality and to deliver it with sensitivity in a way that complements the role of parents and carers, is consistent with the principles and aims of the national guidance, and is linked to other relevant parts of the curriculum, such as religious and moral guidance and personal and social education.

Across our education service, denominational and non-denominational schools have made considerable progress in developing and delivering sex and relationships programmes. This strategy reinforces and supports their work. It is important that that work is supported by accessible health services. There is no single model for the development of links between health services and schools. Good and effective practice will involve collaboration between education authorities and health boards, in close consultation with the school community and in line with national guidance. The aim here is to ensure that pupils across Scotland have similar information about sexual health services and how to access them. Furthermore, we reaffirm our policy that the morning-after pill will not be available in schools.

Therefore, my clear message to young people is, "If you have got a question about your sexual health and you go and see a teacher, they will either offer you the help that you require or direct you to the appropriate service."

Our challenge is to secure a cohesive, seamless approach to clinical services. The fundamental principle that we are setting out is that every person should have a choice when accessing sexual health services and should be able to self-refer. Service redesign will be required to make best use of resources, with geographical outreach and extended opening becoming the norm. In particular, there must be a greater focus on rapid access to community-based care. To help to drive that process, each national health service board will be required to appoint a lead clinician to integrate sexual health services within their communities.

I believe that that is the right strategy for improving Scotland's sexual health, but it will be the quality and determination of our leadership that will be crucial to its success. There will be leadership at national level through the national advisory committee, which I will chair. At local level, there will be leadership through the work of health boards—an executive director will be nominated at board level and a lead clinician will be appointed to drive forward the practical action that we have set out in our strategy. For NHS Quality Improvement Scotland, leadership means developing the right clinical standards to ensure consistency and quality in services across the country. There must also be leadership in the home, through the responsibility of parents and carers to support and guide their children as they grow in maturity and confidence.

Leadership and action are important, but resources are significant too. I am pleased to announce £15 million additional investment to deliver front-line services over the next three years.

Improving sexual health is about valuing and promoting respect for ourselves and for others and about nurturing our young people so that they grow up with the information that they need and with the confidence to make the choices that are right for them. For us adults, it is about taking responsibility for our actions and for our health. Today we have the opportunity to make a difference, but it demands the collective effort of everyone—parents, teachers, local authorities, health boards, ministers and indeed the media—to face up to that challenge and to turn the past months of debate and discussion into action. I believe that we can meet that challenge.

I thank the minister for providing me with an advance copy of his statement. Given the poor state of Scotland's sexual health, as outlined by the minister, it is disappointing that we have had to wait such a long time for the statement. In fact, it is five years since it was first mooted by Susan Deacon, when she was Minister for Health and Community Care. However, we welcome it now that it is here. In particular, we welcome the fact that the minister is prepared personally to oversee the national sexual health advisory committee and to chair it.

What are the timescales for implementation of the strategy? It appears that no timescales at all are given in the action plan. For example, when will health boards and local authorities be expected to have their local strategies in place? Does the minister believe that the £15 million additional investment for the next three years will be adequate to deliver the strategy, particularly given that John Reid announced £300 million for the sexual health strategy in England and Wales? Will the minister keep the level of funding under review as the strategy is implemented?

I welcome Shona Robison's comments. On the delay, as I have said frequently, the real task for the Government is to get it right and I believe that the comprehensive measures that we have taken to ensure extensive consultation will allow us to get the buy-in that we need collectively to ensure the strategy's success. Although I want any Executive strategy to develop quickly, it is more important to ensure that it is developed properly. I believe that the extensive consultation and the work of the expert group have been significant in allowing us to reach the point that we have reached today, where I think that we will get community buy-in for the Executive's approach.

I am happy to oversee the work that we are doing personally, because sexual health clinicians have advised me that they sometimes feel as if they are the Cinderella part of our health service. I want to ensure that my personal involvement in overseeing the strategy gives it added weight and determination for delivery. I shall, of course, point out to health boards that they must provide professionals at local level to deliver the strategy.

I have to say that we have not been doing nothing in the meantime, and some of our statistics on teenage pregnancies and other such indicators have been improving. Nonetheless, we now have a comprehensive strategy. I have indicated in the strategy that we intend to use the centre for change and innovation, which is a successful part of the Executive, to bring clinicians together to develop the very point that Shona Robison made about implementation. It will not happen overnight, but within the next month the centre for change and innovation will get all the clinicians and experts in the field together to ensure that we can roll out the strategy and deliver it. As soon as that event has been held, we will begin to work to a reasonable timescale.

There is no point in me as a minister saying, "Let's have the strategy in place within six months." Issues of recruitment and training are involved and other aspects have to be dealt with. I also want the Executive's performance statistics to reflect the work that we will do on the strategy. Although there are a number of aspects to this work, the member can rest assured that we will not delay it. We want to deliver the strategy as quickly as we can, but we want to do it in a way that allows us to harness the support of the clinicians who are involved and, indeed, the wider community.

I thank the minister for providing us with an advance copy of his statement. I am particularly pleased to hear his comments about the encouragement of personal responsibility for one's own health and the need to have respect for the care and health of those for whom one has a responsibility. I appreciate the comments that he made about the family. I also appreciate the assurance that the minister gave that the morning-after pill will not be distributed like sweeties in a school—[Interruption.]—because of the danger to long-term health, I should add.

The minister said that parents and carers will be consulted. Surely the role of parents and carers is stronger than that. Will he assure them that they have the right to decide what their children should be taught, by whom and at what age? I am not arguing with the right of parents to buy into a school model; they have the choice to do so. Will the minister assure parents that if, having made that choice, they do not like the options that they are given in school, they can take action on the matter?

The minister said a little about abstinence-plus. I understand the role of abstinence in this area. It may not be an option that everyone can follow, which is fine, but when the minister talks of abstinence-plus, is he talking about the risks that someone takes in getting involved in what is a serious relationship step in their life as they grow up as a child or is he simply talking about mechanics?

As I said to the previous member, I say to David Davidson that he does professional colleagues in the health service a great disservice when he uses the sort of language that he used at the beginning of his question when he referred to the distribution of the morning-after pill as being like the distribution of "sweeties". That was an incredibly inappropriate remark. That does not happen in the real world and the member should refrain from using such language.

Parents and carers are an integral part of the strategy, particularly in terms of the work that we do in education. If we could get past some of the headlines to some of the facts, we would find that parents can inspect all the materials that are being used and discuss the content of programmes with teachers. I recommend the useful guide "Sex Education in Scottish Schools: A Guide for Parents and Carers"—the member should read it closely. The guide tells parents and carers what will be taught in the school environment and gives them details of how to speak to head teachers and guidance teachers on these matters. It is absolutely the case that parents and carers are built into the strategy. Parents also contribute by the work that they do in schools through representative bodies.

It is clear that the rights and responsibilities of parents are set out in the strategy. Sometimes I wish that parents would take more interest in these matters. Parents should use the available resources and influence the process that happens in the community as a whole as well as in the school. As the member rightly said, at the end of the day, the parent has the right to decide on the education of their child.

The Scottish Liberal Democrats welcome the minister's statement. The key issue for us is the confirmation that he made that the Executive is determined to ensure that access to sexual health advice and services for all our young people, whichever state school they attend, will be available on an equitable basis right across the nation.

In practical terms, it is clear that many young people are reluctant to go to their general practitioner or hospital clinic for sexual health advice or contraception because of their fear of a lack of confidentiality. Will the minister confirm that, under the Age of Legal Capacity (Scotland) Act 1991, a person under the age of 16 has the legal capacity to consent to their own medical treatment? Will he also confirm that with that right comes the right to confidentiality for that young person on the same basis as for an adult?

That is absolutely the case. Under section 2(4) of the 1991 act, such a guarantee is given in absolute terms to young people who are

"capable of understanding the nature and possible consequences of procedure or treatments".

Minor exceptions are made, but only in cases where there is the suspicion of abuse or criminal exploitation. With those exceptions, the right to confidentiality should be respected absolutely.

Of course, we are talking about confidentiality not only in the school environment but in rural communities across Scotland where the GP is well known and a young person may not feel comfortable about going to see them—the GP may be a family friend who may see the family in the community. Therefore, we are putting resources into the system to ensure that we get a good geographic spread of services.

I was remiss not to address David Davidson's point about abstinence-plus, which is designed simply to ensure that young people make the choices that they want to make. It addresses the needs of young people to understand their bodies and their sexual health and to have the negotiating skills, confidence and ability to say no and feel comfortable about saying no. The Executive wants to ensure that it supports them. However, as I said earlier, the message is, "Delay until you're ready, but be safe when you are active."

I, too, am grateful to the minister for his statement, but will he say which of the expert reference group's recommendations will not be taken forward by the Scottish Executive?

I spoke to the chair of the expert group just before I came to the chamber and firmly believe that the Executive has taken on the vast majority of the group's recommendations. However, perhaps we differ in one area—the one-week issue relating to abortion. The expert reference group said that the maximum time should be one week, but we have stayed with the three-week guideline. Keeping the maximum time between the first appointment and termination to three weeks is proposed by the Royal College of Obstetricians and Gynaecologists, and the Executive thought that that was appropriate. There may be differences as the discussion unfolds, but I would argue that we have taken on board the vast majority of the expert group's recommendations.

Like other members, I welcome the opportunity to see the final draft of the Executive's strategy and look forward to having a full debate in the Parliament on the topic—I hope that the Executive will give us that opportunity once we have had time to read the full document.

The minister knows that I have concerns about the language of abstinence-plus and the risk that some groups that are promoting what is often called "abstinence-based" sex education may gain greater competence to deliver what I regard as ineffective and sexist material. I hope that the minister will take this opportunity to rule out the use of such material.

I do not know whether the minister listened to BBC Radio Scotland at lunch time, but I was involved in a discussion on it in which it was made clear that a campaign group had been given access in advance to the final draft of the document. Will he clearly confirm or deny whether that is true, and whether groups that campaign against sex education were given it before the expert group and the Parliament?

I am unaware of any documents having been given out to any campaign groups prior to this debate and I would be interested to know the details. I did not hear the programme, but there have been many misreports, including a claim that I was holding private meetings with the Catholic Church and everybody else involved in the matter. I have never held private meetings—I hold open meetings. If someone in a dog-collar turns up at the door and says, "I'm the cardinal and I'm here to meet Andy Kerr," I hardly consider the meeting to be private. When we have meetings in the garden meeting rooms and there is glass on all sides, such meetings are hardly private. I am happy to be clear about whom I have met and with whom I have discussed matters. The fact that we need to talk more about such matters in Scotland is at the heart of the debate. Our inability and lack of maturity to discuss such important issues are a real problem in Scotland.

I move on to the more substantive part of Patrick Harvie's question—the language that is being used. We are talking about abstinence-plus and comprehensive sex and relationships education. That is what we mean and what we have made clear in the strategy, and that is what we expect to be delivered as a result of our efforts.

I welcome the publication of Scotland's first national strategy and action plan for improving sexual health and am sure that the minister shares my concern that it is vital that aspirations are translated into action.

In that context, why has the minister decided not to accept the expert group's recommendation to appoint a national co-ordinator? The mechanism of a national co-ordinator or dedicated staff has been used to progress matters relating to changing diets, smoking and physical activity. Why is there no such mechanism for sexual health? I am sure that the minister would agree that committees—even committees that are led by ministers—are not enough in themselves to drive change throughout Scotland.

Secondly, I ask for an assurance that when the minister has the meeting that he described earlier and targets and timescales are produced, those targets and timescales will be not only for more strategies and plans but for changes and results on the ground.

Finally, what measures will the minister put in place to monitor resources that are targeted at the strategy to ensure that they end up in sexual health and are not diverted into other areas of spend?

I am more than happy to seek a debate in the Parliament on our sexual health strategy. We did not go for the position that the expert reference group adopted because we wanted to ensure that all our efforts went into front-line delivery. The less bureaucracy we have, the more action there will be on the front line. We are delivering more services in communities, as members have mentioned. I wanted to ensure not just that the money goes to the front line instead of into bureaucracy, but that we have the added weight of the minister being directly accountable to this Parliament and responsible for the delivery of the strategy, rather than getting someone else to do that on our behalf. Nonetheless, that is appropriate on other occasions.

As regards targets and timescales, it is clear that the centre for change and innovation event will get the clinicians together with the wider clinical community and lay out the action that we should take. I wrote today to all health board chiefs and local authority leaders to tell them that we want to get that work going. At the heart of the matter is our desire to ensure that we set appropriate targets and timescales for Scotland. The sexual health issues in Glasgow to do with access to services, population profile and needs are radically different from those in other parts of Scotland, such as Lothian and Highland.

We want to ensure that we build the clinicians into the process as well as users of the service in order to get it right. The process will be monitored through changes that we will make to the health service performance assessment framework so that targets can be set. The work of NHS Quality Improvement Scotland, which will set out a regime of monitoring the performance of health boards as they deliver the strategy, will give us some reassurance that the strategy will achieve the results that we seek.

I welcome the publication of the strategy and the opportunity to debate it when we have had time to digest all its implications. I have a couple of specific questions for the minister after reading both his statement and the strategy. He said in the statement:

"The aim here is to make sure that pupils across Scotland have similar information about sexual health services and how to access them."

Will the minister tell me about the difference in access to information between schools? I am sure that he agrees—if he does not, he will contradict me—that there should be an equal right of access to sexual health information and services. With that principle in mind, I draw attention to concerns about an area of the strategy.

Come to your question quickly.

The last bullet point on page 18 of the strategy talks about supporting school nursing teams by providing opportunities for them to update their skills. Surely if there is equal access to information, school nursing teams must have updated sexual health skills and should not have to opt in or out. Will the minister reassure me that all school nursing teams will have equal education and information and will provide equal services?

The word that I used in my statement was "similar". We are taking a child-centred approach based on individual children and classes and the way that the school works. As long as the framework that was set out in the McCabe report—which was widely welcomed and is being implemented successfully throughout Scotland—is addressed, there is no need to be prescriptive. One cannot dictate from the centre the maturity of pupils, the difference in approach or the location of any school. I put trust and faith in the professionals in the service to work within the framework that we set to ensure that the services are delivered in an appropriate fashion.

I expect every school in Scotland to ensure that the McCabe principles and framework are delivered. Her Majesty's Inspectorate of Education also looks into these matters. At the end of the day, it is right that there are differences in the decisions that are made by individual schools about teaching materials and that there is no absolute prescription from the centre. At the heart of the matter lies a fundamental principle: if a young person in any school in Scotland needs to get advice about their sexual health, either they can get it from a teacher in the school environment in a way that is appropriate to that school, or they will be directed to another source of advice in the community. That is what the strategy says.

There are issues to do with the recruitment of new staff, training and the updating of skills. I understand that the training of school nurses is on-going, but I am more than happy to address Carolyn Leckie's specific point in correspondence later.

I, too, welcome the strategy and commend the Executive for encouraging the Scottish Civic Forum to become involved in carrying out consultation meetings throughout the country. I also welcome the minister's comments about monitoring. However, will he consider introducing stakeholder monitoring to ensure that people in communities and young people feel the effects of the strategy? Will he provide some idea of how monitoring will be carried out? Will organisations such as the Scottish Civic Forum be involved in future to ensure that this welcome strategy does not end up in a drawer somewhere without making the difference that it is intended to make?

It is clear that we need to make a real difference to the improvement in health in Scotland, and sexual health is a significant aspect of that.

The resources that we have set aside for the strategy include money to continue research on the matter. Since I became the Minister for Health and Community Care, I have been pleased to find out how much the NHS involves user groups, patients and other service users in developing services. As far as this strategy is concerned, that approach will not change. The member should rest assured that all the organisations that have taken the time to become involved in developing the strategy—for which I thank them—will be written to either today or very soon with the results of their involvement. We want an on-going dialogue. Of course, we use all the different aspects of Scotland in different ways. For example, we have involved the Executive-supported Young Scot, the Scottish Youth Parliament and other forums to ensure that young people continue to play a significant role in developing these services.

I thank the minister for displaying good faith in his statement and by taking on the leadership of the national committee. However, does he still think that £15 million is a sufficient amount of funding for all local authorities?

Secondly, how will the strategy be implemented in our schools? After all, the Minister for Education and Young People has indicated that all schools are to become community schools, with access to health and social services. What role would HMIE play in carrying out joint inspections with social work and health? How will the Minister for Health and Community Care ensure that local authorities provide all pupils with equal access to services and who will judge whether any similar information on such services should be used to ensure that access?

The member has raised many questions. I will do my best to deal with all of them, but I will be very happy to correspond with her about any that I forget to address.

HMIE, NHS QIS, the performance assessment framework indicators—in other words, the health service's accountability framework—and the accountability reviews that Rhona Brankin and I will carry out and that will hold local health chiefs to account about the strategy's delivery will all play a role in addressing the issue that the member has raised.

As with any aspect of public expenditure, we must ensure that we are using our existing resources as effectively as possible. The work that we will carry out with the centre for change and innovation will help us in that process. The current budget for specific sexual health initiatives is about £10 million, and health board budgets also contain a general allocation. Therefore, an additional £5 million represents 50 per cent more funding going into the system. My worry is that we will not organise things quickly enough to ensure that the money makes a difference in the front line.

As I should have said in response to Shona Robison, we must get the money into the system and ensure that it starts making a difference to the scope and the geographical aspects of the services that we provide. We need more specialists, consultants, general practice specialists and nurse specialists in the front line. Furthermore, we must enhance our testing capability. That is a significant element of the strategy and resources will also be used to improve drop-in facilities.

I think that the member is comparing us with another part of the United Kingdom that has also announced a sexual health strategy. We decide here on the appropriate measures for Scotland and our decisions are based on feedback from clinicians and other parts of the country about what we need to do. The Executive has focused on what it thinks is needed and will make a difference. By chairing the national committee, I will ensure that that work continues. If targets are not being met and more resources are needed, we will obviously review the situation.

I, too, thank the minister for his comments, especially on the central role that parents and teachers will continue to play. However, is he aware that, despite what he has said, some people will misinterpret or misunderstand the Government's strategy and that misinformation about the material that circulates in our schools continues to create unnecessary anxiety in families? Will he reassure me and parents, families and pupils throughout Scotland about the content of the material in our schools and about the safeguards that are in place for parents and teachers?

Teachers in schools have a statutory responsibility to ensure that their teaching materials are appropriate. I have personally gone through the teaching pack for teachers to see what it said and what images were used. I was quite comfortable with it.

I want to go back to the fundamental point: we want to reassure parents that they have access to all this information if they want it. They can discuss these matters with the head teacher and the guidance teachers responsible. I give an absolute reassurance that there should be no inappropriate materials in our schools. I am confident that there are not.

The way in which the media present these issues is a big challenge for us. I want to ensure that editors take a responsible approach to the issues and do not flare up over claims that are unfounded or inaccurate. We want to work with the media to ensure that we do not cause parents unnecessary concern. I have every faith in the media that we can work in that way.

Power rests with the parents. As I said to David Davidson earlier, parents can access the information and can speak to the teachers. If they wish to, they can withdraw their child from the teaching. I would not recommend that course of action, but the power exists.

I have allowed the clock to run on, but I am afraid that I cannot let it run on any further. I express my regrets to the two members who wished to speak but were unable to. We could have called everyone, but we have had a degree of multiple questioning, which is unfortunate.