APPENDIX 41
Memorandum by Royal College of Nursing
of the United Kingdom (SH68)
1.SUMMARY
Sexual health has never been higher on the nursing
agenda. Over the past two years the RCN has been actively involved
in the development of nurses' roles across all specialist areas
of health care provision.
—The RCN recommends that education and
training be developed to enable nurses to address the sexual health
needs of all clients.
—The RCN believes that school nurses should
be able to prescribe emergency contraceptive pills.
—The RCN would like to see the regional
inequalities in HIV funding addressed as well as an end to delays
in allocations.
—The RCN believes that the Government should
ensure that condoms are universally available in prisons.
2.INQUIRY TERMS
OF REFERENCE
The Committee will examine the effectiveness of the
Government's strategy for sexual health in the context of the
consultation document Better Prevention, Better Services, Better
Sexual Health: the National Strategy for Sexual Health and HIV.
3.INTRODUCTION: ABOUT
THE ROYAL
COLLEGE OF
NURSING
With a membership of over 340,000 registered nurses,
midwives, health visitors, nursing students, health care assistants
and nurse cadets, the Royal College of Nursing is the voice of
nursing across the UK and the largest professional union of nursing
staff in the world. RCN members work in a variety of hospital
and community settings in the NHS and the independent sector.
The RCN promotes patient and nursing interests on a wide range
of issues by working closely with Government, the Westminster
parliament and other national and European political institutions,
trade unions, professional bodies and voluntary organisations.
The RCN's sexual health strategy was developed to
help nurses' work effectively in the field of sexuality and sexual
health and was launched in June 2001.[22]
The RCN is proactive in sexual health across the UK and is engaged
in several pilot projects in specific areas. The RCN's Sexual
Health Forum has 27,000 members and is represented by committee
members on Department of Health committees on sexual health in
all four countries. Nurses work in the three levels of professional
care delivery: generic nursing services (non-primarily sexual
health), generic nurses in sexual health environments and specialist
nurses in sexual health environments.
With nurses working at the direct interface between
clients and their sexual health needs it would seem a lost opportunity
not to engage them in more proactive sexual health strategies
that are relevant to both the local and national arenas. Nurses
are in schools with young people, part of the UK's most sexually
active group. Nurses are present in primary care settings and
in outreach work to dispossessed and socially excluded individuals/groups.
Nurses are also there in health care settings, when clients present
with worries and anxieties, sexual health problems and difficulties.
4.DEVELOPING CARE
Many nurses work in the proactive arenas of developing
care. These include nurse-led facilities and clinics, in outreach
work with commercial sex workers and injecting drug users, in
facilities offering new and innovative services such as nurse
prescribing, NHS Direct and contraception administration.
The RCN Richard Wells Award is given annually to
a nurse who works in the area of sexual health and has carried
out innovative work in their specialist area. Last year it was
jointly awarded to two nurse practitioners who worked with street
prostitutes in Belfast. Since the award, the nurses' project has
received mainstream funding. This is typical of the type of innovative
practice that nurses are undertaking.
5.NURSE EDUCATION
AND TRAINING
There is currently no mandatory sexual health component
in nurse training and education. The RCN has stated that nurses,
midwives, health visitors, specialist nurses and nurse consultants
need to have specific sexual health care practice education and
training programmes. Syllabuses for pre-registration nurse pilot
projects must include sexual health and post-registration nurse
education projects should be flexible to meet local education
and training needs. The low priority frequently given to sexual
health means that good quality courses and projects are not available
to all nurses.
Many people who come into a health care setting are
not seeking help for sexual ill-health problems. Their illness
or disability may well have an impact on their sexual health and
sexuality and nurses need to have the expertise to offer help
or know how to find appropriate support. There is currently little
provision for sexual health training in learning disabilities
or mental health nursing. There may be particular issues for nurses
working with patients in long-term residential care and those
with chronic illness such as MS or Parkinson's disease.
The RCN has produced a distance learning pack for
practice nurses to assess, manage and treat erectile dysfunction
arising from conditions such as diabetes and hypertension. This
has been utilised by 1,200 nurses, some of whom are now running
nurse-led services.
6.TRAINING THE
TRAINERS
Nurse educators do not necessarily have the skills
to teach sexual health. Consequently it can be taught in insufficient
detail or be missing entirely from a course. Most teaching is
carried out in practice by mentors, assessors and clinical practice
educators. There should be training to ensure that effective sexual
health teaching is included in the practice setting. Clinical
supervision can be used to explore sensitive issues and offer
support to staff.
7.SPECIALITIES
The Government set the target of reducing teenage
pregnancy by 50% by 2010. There is a very important role for school
nurses in this area. School nurses are taking sexual histories
of sexually active teens and giving comprehensive advice on sexual
health. The RCN believes that all school nurses should be able
to prescribe emergency contraceptive pills.
8.CONSULTANT NURSES
IN SEXUAL
HEALTH
Three consultant nurses in sexual health have been
appointed so far in England. Career pathways for these nurses
include the development of the RCN sexual health programme that
incorporates policy, practice development, research, and life
long learning.
9.CAREER PATHWAYS
There are often no clearly defined career structure
or growth pathways in sexual health nursing. For example, there
is no direct route from D grade to consultant. This may adversely
affect the recruitment and retention of nurses working in sexual
health. The RCN strategy has suggested that enhancing the career
profile and pathways of nurses in sexual health include the enhancement
of sexual health per se. This can be achieved by three stages.
Stage one encompasses sexual health aspects in generic areas of
care especially where there are clearly identified sexual health
components related to the profile or practice areas, for example,
school/young people's nursing, primary health care settings and
gynaecology and termination of pregnancy services. Stage two covers
education and professional development for (generic) nurses working
in sexual health services. For example, nurses new to post who
require more specific qualifications in areas such as HIV and
GU nursing and safer sex and contraceptive services. Stage three
includes education, professional and career development for specialist
qualified nurses working in their specialist sexual health field,
for example, relevant higher or advanced professional/academic
qualifications, psychosexual counselling, gender reassignment
services and nurse-led sexual health projects.
10.THE EFFECTS
OF HIV FUNDING
CHANGES ON
NURSING AND
RELATED SERVICES
Until April 2002 HIV prevention and treatment/care
funding was devolved to health authorities as a special allocation.
These resources were ring fenced or earmarked explicitly for HIV/AIDS.
This has now ceased and these funds are now subsumed in the mainstream
budgets of primary care trusts.
Over the past seven years concern has been expressed
that these allocations have a) fallen behind the incidence and
prevalence of the disease, and b) have created inequalities in
resources given to the different regions of England. Also in the
last two years the Department of Health has created problems for
health authorities by delaying announcement of the following year's
allocation.
For more than 10 years a series of papers and reports
have identified inequalities in HIV treatment and care funding
across England[23],[24]
,[25].
These inequalities generally mean that regions in the south of
the country (South West, South East, London, and Eastern) have
received and continue to receive significantly more money for
each person in HIV treatment than regions in the north[26],[27].
In 1999 the Department of Health undertook a stocktake
of HIV treatment and care funding. The stocktake was to develop
a new funding formula along the principles of equity and clarity.
The stocktake developed a formula that moved allocation of HIV
treatment and care funds to a health authority residence based
formula; allocating funds on the basis of the number of HIV positive
residents in each health authority. However, as part of the stocktake,
health authorities were asked to identify HIV treatment and care
money they were actually spending on other services (GUM and other
issues). From a total of around £70 million almost £50
million was identified as spent on GUM, with the rest on "other"
issues. The better funded regions in the south, especially London
and Eastern, account for most of this misspend.
The £70 million was not reallocated and was
removed from HIV funds nationally. However, the Health Authorities
who had been spending this money were allowed to retain this misspend,
largely under the heading GUM funding, which was paid into their
general allocations. As a result of this re-labelling of HIV/AIDS
funding, money that would have come to the North West will now
remain in the South and many southern health authorities that
were over-funded now look under-funded with their over-funding
no longer appearing under the HIV heading.
What the stocktake did identify was that together
many southern health authorities have (for a number of years)
been receiving an excess of around £62 million (89 per cent
of the misspend) to fund additional GUM/HIV services. Not surprisingly,
services in the North West have been at a substantial financial
disadvantage and have suffered. Analyses of the most recent epidemiology
on HIV deaths shows that HIV positive residents of the North West
are 68% more likely to die during a twelve month period in contact
with services (than their counterparts in London). The North West
has been disadvantaged for a number of years by inequitable HIV
treatment funding and the new funding arrangements have not redressed
the balance.
11.PRISON NURSES
Nurses working in prisons frequently provide sexual
health promotion and treatment programmes. It is clear that many
prisoners need education on blood borne viruses and SAIs and their
treatments. Staff, especially nurses, must have adequate skills
and training. In addition, the RCN believes that the Government
should ensure that condoms are available in prisons.
RECOMMENDATIONS
Education
The RCN recommends that education and training to
enable nurses to address the sexual health needs of clients should
be:
—on the wider focus of sexual health for
all;
—with specific focus on safer sex and contraception,
for people who require these services;
—pro-active in sexual health promotion,
specific to individuals, groups and their targeted needs, without
leading to stigmatisation (eg in various sexual risk or vulnerable
groups);
—capable of addressing specific sexual
problems and illnesses; and
—instrumental in developing practice and
enhancing related (local and national) policy issues.
School nurse prescribing
The RCN believes that all school nurses should be
able to prescribe emergency contraceptive pills.
HIV funding
The RCN would like to see the regional inequalities
in HIV funding addressed as well as an end to delays in allocations.
Sexual health in prisons
The RCN believes that the Government should ensure
that condoms are universally available in prisons.
June 2001
22 RCN June 2001 RCN sexual health strategy: guidance
for nursing staff. Back
23
Tolley K, Maynard M. Government Funding of HIV-AIDS Medical
and Social Care, Discussion Paper 70, Centre for Health Economics,
York University, 1990. Back
24
Cosgrove P, Lyons MW, Bellis MA. Economics of HIV and AIDS
in the North West of England, Public Health Sector, Liverpool
John Moores University, 2001. Back
25
Bellis M, McCullaugh J, Thomson R, Regan D, Syed Q, Kelly T. "Inequalities
in funding for AIDS across England threatens regional services",
British Medical Journal, Vol.315, pp.950-51, 1997. Back
26
Cosgrove P, Thomson R, Bellis M. "Equitable strife",
Health Service Journal, 4th January, 2001. Back
27
Bellis M, McVeigh J, Thomson R, Syed Q. "The National Lottery",
Health Service Journal, 17 June, 1999. Back
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