APPENDIX 46
Memorandum by the Special Interest Group
British Association of Social Workers (SH73)
INTRODUCTION
The SIG was established in December 1990 to provide
advice, information and support to social work and social care
staff under the auspices of the British Association of Social
Workers (BASW). Following changes to the Charity Laws, the SIG
had to apply for its own charity status, which was successful
in the late 1990s and subsequently the SIG then became affiliated
to BASW and extended its remit to cover HIV and Sexual Health
and extended its full membership status, with voting rights, to
any person over the age of 18, holding a social work qualification
which is recognised across the British Isles, or who is currently
working in the provision of direct social care, education or HIV
related Health Promotion and Psychology across the statutory and
non-statutory sectors, including the Prison and Probation services.
Student membership, with full voting rights, is offered to any
full-time, self-funding/or in receipt of a recognised grant eg
LEA/CCETSW student on any social work, education, health promotion
or psychology course. Anyone not falling in to either of the above
categories can apply for associate membership with no voting rights.
The current objectives of the SIG are:
1.To promote models of good practice and endorse
the principles of involving service users in planning
their own individual services.
2.To review, inform and determine good policy
and practice in relation to HIV social care, education,
health promotion and sexual health.
3.To create a forum for information exchange
around issues related to practice, resources and on-
going training.
4.To raise the profile of HIV infection and related
issues with a view to developing awareness and
positive attitudes.
5.To develop sensitive mechanisms of support
for members on an individual and/or group basis.
6.To keep the integration of HIV and Advanced
HIV issues into training practice and policy on the
agenda of agencies and to promote service delivery,
which is reflective of equality of opportunity
and diversity.
7.To be pro-active in creating mechanisms for
liaison, consultation and communication with relevant
agencies—statutory and non-statutory.
RESPONSE
We are intrigued as to how we can comment on the
effectiveness of the Government's strategy for sexual health,
when this long overdue document has still not been launched. Surely
the time to comment on effectiveness is after it has been operational
for three to five years. However, we do have several concerns
as to the contents of the draft strategy, which were submitted
to the Department of Health and are attached for your attention.
HIV continues to be a highly-stigmatised condition
and is one of the most serious communicable diseases. Evidence
(APPGA, 2002) suggests that a significant difference can be made
to both the rates of transmission and the lives of people who
are living with and/or affected by HIV if the following are addressed:
tackling lawful and unlawful discrimination and social stigma
directed at people who are known to be HIV Positive, social security
rules, the education system (although we note some attempt has
been made re the delivery of sex and relationships education),
the social exclusion of lesbians, gay men and asylum seekers,
the poverty and racism experienced by many ethnic minority communities
living in the UK. Disconcertingly, we note with a degree of alarm
the increase for the second year running in the reporting of new
infections. HIV contributes to the cycle of social exclusion experienced
by some groups of people and is a significant contributor to health
inequality, particularly in low prevalence areas. An example of
this is the marginalisation of Social Work staff in the provision
of support services to service users living with and/or affected
by HIV.
Since the decline in funding to LAs since 1995, many
specialist posts have disappeared, with a resulting lack of service
provision, especially in low prevalence areas. The emphasis on
creating generic teams has also meant that staff with specialist
knowledge are often no longer available and staff within generic
and specialist teams are often restricted on being able to access
vital professional development in this field. Special allocations
have been recognised as being one of the "tools" that
are particularly effective in the Health Service, though we acknowledge
are clearly not the only system of control. Central government
drives the work in relation to Teenage Pregnancy, Drug and Alcohol
use and misuse. We do not believe that there is any evidence as
yet to suggest that HIV no longer needs this central drive.
Social work and social care staff have a vital role
to play in the field of HIV and sexual health as full partners
in service delivery and not as the poor relation. Furthermore,
experienced social workers in the field of HIV have become skilled
health promoters, which has enhanced their service delivery and
level of support that they provide to their service users. An
example of the marginalisation is the highly visible lack of social
work staff on Primary Care Trusts, we would strongly recommended
that the balance is redressed to reflect equality of opportunity
and diversity across local areas. After all General Practice has
clearly not shown itself free of the prejudice directed towards
HIV. People with HIV do not and will not use general practice
unless there is a significant change in the approach to HIV seen
in general practice, consequently service users will continue
to access all medical and some social service provision through
departments of Genital Urinary Medicine, or will they in light
of potential changes to the access to information as recently
announced by the government. We also welcome the commitment to
partnership with voluntary sector organisations, however like
many social care agencies, the HIV voluntary sector has become
severely compromised, particularly in light of the growth of the
Terrence Higgins Trust.
Equally, as APPGA[28]
have consistently stated, the strategy needs strong and visible
political backing to help tackle some of the inequalities and
discrimination. We strongly support APPGA and its recommendation
that the strategy be given the status of a National Service Framework,
which would promote cross-departmental and cross-agency working.
A further recommendation that we back is that the Social Exclusion
Unit addresses HIV in a one-off investigation that considers the
role of other government departments, with particular attention
to Education and skills, Work and Pensions and the Home Office.
We would welcome a more active role in any consultation
process re the implementation of the strategy.
Annex
Response to the National Strategy for
Sexual Health and HIV document
SUMMARY
Penultimate Paragraph
The SIG are concerned re the £47.5 million that
the Government are proposing to invest in new initiatives. Where
is this money coming from? What is the projected growth rate over
the 10-year period? How will this money be protected in the next
parliamentary term? Who will be the budget holders? How will it
be allocated? For example, there have been anomalies in the allocation
of the AIDS Support Grant and other HIV funding since its inception
and in the way it has been spent, for example—there are
many health authorities that built car parks and GUM clinics with
HIV monies.
SECTION 1
Introduction
How will the proposals and recommendations contained
within the document relate to similar in the sexual health strategies
of Wales, Scotland and the British Isles? After all our members
work with clients who are from many different countries worldwide,
and with clients who move around the UK and British Isles—due
to work, family and leisure.
Para 1.8
Where is the proof for the assertion that "three
quarters of the newly diagnosed infections in the year 2000, were
in the heterosexual community and "probably acquired abroad."
Therefore this paragraph focus has yet again reinforced stereotypical
opinions that the majority of infections were between men who
have sex with other men. If differentiation is being made because
of targeting services in the most appropriate way, then this is
acceptable, however reinforcing stereotypes is not. Particularly,
as one of the main strands of the document is about targeting
young people and emphasising prevention of all sexually transmitted
infections (STIs). However, as some of our members have pointed
out, for many young people prevention is not seen as relevant
to them as they think STIs, including HIV are "not their
problem"!
Para 1.11
Members agreed with the sentiments behind this paragraph
re young peoples' lack of knowledge, however the issue of chlamydia
raises an interesting point. Due to the lack of awareness raising
through publicity campaigns and information, including the media,
young people and older people do not know what chlamydia is. For
example, the information available from Health Promotion England
makes an attempt but the image portrayed appears to only be relevant
to young white women in the 16-24 year age range, ignoring all
other black and minority ethnic groups and the male population—regardless
of sexual orientation, racial/cultural backgrounds, age, disability
etc.
Para 1.16
What is meant by the term "sexual ill health"—does
it mean medically, socially or another definition?
Para 1.17
Whilst agreeing with some of what is stated in this
paragraph we would dispute the bias on "poorer" (whatever
that might mean) teenagers being 10 times more likely to become
pregnant than those from "wealthier" (whatever that
might mean) backgrounds. Surely the emphasis here should be on
issues of education, self esteem and confidence building.
Para 1.18-20
We agree with inequality of service provision throughout
the UK and British Isles. However, we were disappointed not to
see proposals for how this will be tackled. It would have been
useful to have a text box with the summary proposals from the
NHS plan within this document. Not all of our members have the
luxury of being circulated with both documents.
Para 1.22
It was interesting to read about the availability
of community family planning clinics. Many of these clinics have
been either shut or had their services scaled down due to lack
of funding and shifting priorities in NHS Trusts and PCG/PCT's.
Many are not accessible to all service-users, or service users
feel excluded because of their sexual orientation.
SECTION 2
Para 2.4-5 and 3.5
How will the promise that "everyone will have
better access to `good' services ..." be kept, maintained,
monitored and reviewed? There are implications for different agencies
and organisations, for example: Young people's sex and relationship
education (SRE). In England school governors have the responsibility
for deciding how this should be provided and in what depth. This
means, despite DfEE (now DfES) guidance issued in 2000 that many
young people only receive the basics that are a statutory requirement
under science orders. Many young people complain that they do
not receive comprehensive SRE and/or receive poor quality sex
education and almost zero mental health and well being input to
enable young people's self esteem and confidence to be developed.
With the introduction of statutory citizenship but not Personal,
Health and Social (PHSE) education this will squeeze the available
time within the curriculum for adequate delivery of SRE. Furthermore,
there is still little emphasis in the majority of initial teacher
training colleges/establishments re PHSE consequently many teachers
feel unable to deliver SRE or they may feel unsupported within
the school from senior management teams who, due to the National
Curriculum and league table pressures stress the importance of
academic work and do not support any increase in curriculum time
for the delivery of PHSE.
SECTION 3
Para 3.7
The use of High Risk groups is not a viable description
and has been out of use for many years. The emphasis in health
promotion and health education is on risky behaviours. Using "high
risk" groups, again focuses attention on stereotypes and
not on prevention or harm reduction.
Para 3.10
Whilst acknowledging the key aims of prevention as
listed, the reality is "poles apart". For example, many
young people now think HIV is curable due to combination therapy
and are shocked to find out that combination therapies are treatment
and not cure. There are concerns being raised by members as to
the unknown levels of HIV and other STIs in those seeking asylum.
Many of these people are either unable or unwilling due to traumas
they may have experienced to seek out diagnosis and possible treatment.
The Refugee Council can provide evidence to support this.
Para 3.14
The second bullet point re supporting the prison
service's strategy for preventing the spread of communicable diseases
is laudable, but again, reality does not match the sentiment.
To be remotely successful, it would require a major shift in the
organisational culture of the service, a major staff and inmate
training programme as well as the provision of resources such
as condoms and needle exchange facilities on a scale and implementation
policy similar to that within the Swedish prison service.
Para 3.16-17
Exactly when in 2002 will the public health campaign
begin? Who is it being targeted and more importantly is this an
empty promise? After all, this draft document was promised in
November 1998. If during the first six months or so then surely
the evidence as to what may or may not work will not have been
gathered in sufficient detail to run an awareness campaign that
will be effective with the general population.
Para 3.20-3.33
There are major resource implications across the
proposals in these two paragraphs. The Government may be committed
to lifelong learning, however the reality is that many employers
are either unable or unwilling to release staff for ongoing professional
development, this is due in part to finding other staff to cover,
the cost of staff training and the location of the training for
staff to access. For example, may SSD in-house training units
were disbanded or the services went out to tender in the mid 1990s.
A further implication of the year-on-year funding of the ASG was
the resulting lack of ability to forward plan, to give staff security
and the opportunity to obtain further professional development.
In Education there is a major shortage of teachers, therefore
getting supply cover to release staff for professional development
in key areas of the NC is increasingly difficult, never mind in
areas of PHSE. Nurses have had PREP imposed on them, yet once
again the reality of them getting released for professional development
is rare. Public sector workers are already demoralised, the suggestion
by at least one Minister (E Morris) that staff should access professional
development in their own time is not attractive to staff thinking
of leaving or discourages returners or new staff. For those in
the voluntary sector, they often do not have the money available
to purchase training and/or are heavily reliant on the goodwill
of the volunteers to give up further time to attend courses, many
of which are only available Monday to Friday during business hours.
QUESTIONS
—Target setting—What did this target
really mean? Reduction of 25% of newly acquired HIV and gonorrhoea—25%
of what? To achieve any change will need a huge change in sexual
health education in the country. Therefore, we are back to adequate
funding and the need to target prevention work.
—"Safer Sex"—Means different
things to different people—culturally and otherwise.
—Most effective interventions—who
really knows? This changes from year-to-year dependent on location,
age, community, sexual orientation, other black and ethnic minority
groups, access to services, evolving languages and use of language,
models of theory and practice, etc.
ACTIONS AND
TARGETS
—National Helplines—Does national
mean national or just England? Is the amount of lines available
going to be increased? Who will ensure the national helplines
have up-to-date information pertaining to all geographic areas?
What about the staffing and training of paid or unpaid workers
on these lines? Many local helplines were receiving very few calls
for information, advice and support re HIV by the early 1990s.
Many voluntary agencies around the UK and British Isles now find
people prefer to access information through websites and on-line
services. However, this again discriminates against those who
do not have access to "e" services or telephones.
—Strategic frameworks—For many people
within the African communities disbursement leads to isolation
and resulting lack of "community identity and support".
They might not know their HIV status or may not want to know their
HIV status due to issues of culture and stigma.
SECTION 4
Para 4.2
Should this read All branches of the NHS and not
Many ...
Para 4.5
The members thought this was an integral part of
policy and practice guidance that went hand-in-hand with the implementation
of the NHS and Community Care Act (1990). Surely it would be better
to support established networks rather than re-invent the wheel.
Members are aware that in some parts of the UK this has been patchy,
but in other areas there have been some excellent models of good
practice eg Birmingham.
Para 4.7
In the HIV field the GP is definitely not the preferred
point of contact for many clients and likewise with many asylum
seekers and refugees.
Para 4.11-24
All of these proposals have huge resources and training
implications, and therefore the need to fund at an appropriate
level. Furthermore a cultural shift is required to ensure that
current and future practitioners will prioritise sexual health
services and place equal value on all "partners" including
clients. In paragraph 4.24 reference is made to the provision
of condoms—will these be free, or offered on prescription
and will sufficient choice be available, as one type of condom
does not suit all.
Para 4.25
Has the DoH been in active consultation with the
few One-Stop Shops that are already up and running, for example
there has been a facility providing this type of service in the
City of Nottingham from the early 1990s (The Health Shop in Hockley).
Para 4.29-30
This will be good news if it comes to fruition.
Para 4.32-4
The issue for many pregnant teenagers or even younger
is that many of these young women do not have the necessary skills
in decision making to be able to make a concrete decision as to
whether or not a termination is the most appropriate way forward.
Therefore they need knowledge and skills to promote their self-confidence
and esteem to enable them to approach the necessary service providers.
Many young women are fearful of going to their GP, especially
if under the age of 16. There are issues here about appropriate
and widely available information to improve potential access,
for example in public conveniences across a wide range of outlets
and venues.
Para 4.44-45
Members supported the sentiment contained within
these two paragraphs.
Para 4.48
Members have suggested that there is also a need
here to consider the fact that many people across all age ranges
do not feel HIV is an issue for them. It is still perceived as
"another's problem".
Para 4.52
Again, 73% of how many?
Para 4.53
A major concern here is where has money been diverted
from to provide this service which in reality has only meant a
very small number compared to the resulting number of children
born and still HIV +ve at the age of two.
Para 4.55
Concern has been raised as to the appropriateness
of offering an HIV test to everyone on his or her first visit
to GUM. This statement is suggestive of prescriptive medical model
approaches to treatment and care as well as the "nanny knows
best" attitude. This policy would need to be handled with
exceptional sensitivity and care, as for some, when the news spreads
that HIV testing is being offered on first visits it may well
put them off from seeking advice, information etc.
Para 4.60
Members have rightly stated that for most of them
in their localities, this is already happening. They would agree
that it may be patchy but resent the fact that this proposal is
being put forward as a new concept. Equally many smaller voluntary
agencies resent what is seen as the Terrence Higgins Trust takeover
and are happy with what they have managed to achieve, borne out
by client satisfaction in many areas of the UK.
Para 4.64
Equally what is crucial to the success of drug treatment
is that the clinical staff acknowledge and value the person who
is living with HIV as having a right to make a choice, which may
change later, about their drug regime whether or not the clinical
staff agree with the persons individual decision.
Para 4.68
Social Care "staff" whether paid or unpaid
will work with their client to ensure they know they have a right
to make choices (as above in 4.64). Social work practice and ethos
is about enabling not creating dependency.
Para 4.69
Members were disconcerted to not see Social Services
mentioned by name, particularly as SSDs had the lead role in drafting
and implementing the NHS and Community Care Act (1990). They said
they felt devalued and would be equally disgruntled to find that
they were under the term of "other key organisations".
Does this mean the end of SSDs?
Para 4.74
Many voluntary sector organisations have closed down
over the years due to the lack of security in the funding arrangements.
Do the proposals within this paragraph mean that a secure and
effective funding plan will be implemented, that goes beyond the
year-on-year bidding round.
Para 4.77
It was felt by some of our members that GUM clinics
will need staff from a mix of professional backgrounds, eg not
just clinical and nursing but also social workers, psychologists,
psycho-sexual specialists, mental health professionals and on-site
laboratory facilites and associated staff. In some areas these
could become the "One-Stop" shops, which would help
reduce the stigma many people still attach to attending GUM Departments.
The ability to make informed consent must not be compromised in
order to reach the targets set out.
Para 4.79
Should the second sentence read: Providers and commissioners
of services will work together with local people ... The
should is a weak statement of intent, especially in light
of some of the prescriptive statements in previous paragraphs.
The next question that arises, is how will this process be set
up to be equitable? Experience has shown via the processes that
were set up after implementation of the NHS and Community Care
Act (1990) that involving "local" people became a tokenistic
and subsequently valueless exercise, that were dominated in some
areas by the Health Authority representatives.
Para 4.81 and 4.82
In the majority of members' localities these proposed
standards are already and have been for some time, in place.
QUESTIONS
—"New Model"—firstly, this
is not a new model it is a re-written invention of an existing
wheel. As has been the case for the last 14 years, these goals
can only succeed if there is a sufficient and planned level of
financial commitment in place. The NHS and Community Care Act
(1990) has failed in part, due to the lack of foresight in how
expensive effective care in the commuity really is.
—Other models—The one-stop shops
need to be out of the medical model domain and established within
areas of assessed need. They need to be seen as an inviting alternative
that will attract people from all ages and walks of life to access
sexual health services. The health promotion campaign that should
run concurrently with these should be one that helps de-stigmatise
and promotes personal responsibilty and good citizenship. A major
cultural change in society is required to empower people to start
talking about sexual health in an open and frank way.
—Targets for reducing—whilst whole-heartedly
agreeing with the theory behind this proposal, we do live within
a democratic society; you cannot legislate that people must use
condoms etc. Strategic frameworks should only be about laying
the foundations of good practice, not about acting as "nannny"
to the general population. The Government and other agencies
may be able to make guess estimates about the numbers of undiagnosed
HIV positive people, but realistically we will never know the
actual number.
ACTIONS AND
TARGETS
Again these are laudable aims, however how will the
Department ensure that these statements of intent will be carried
out? As stated previously the commissioners and service provides
can only meet these targets if the right levels of human and financial
resources are made available.
SECTION 5
Para 5.3-5.15
We have been waiting three years for this promised
draft to be circulated, although the idea and toolkit will be
helpful surely this should have been the starting point for this
strategy. Therefore, is this a case of setting agencies up to
fail before the process has begun. Service providers across all
sectors have identified and been working in multi-agency forums
for many years, JCCs were the fore-runners to the various multi-agency
committees that were established as a requirement of the NHS and
Community Act (1990) Community Care Plans. There are models of
good practice pertaining to community development projects that
have been up and running since the mid 1990s. When discusing "patient"
empowerment and the general public playing a part in re-shaping
sevices, wasn't this the supposed outcome of the consultation
exercise that took place in 1999, where the general public were
asked to complete questionaires about the NHS. Is this a case
of this setion having been started in 1997, ready for the consultation
exercise that should have begun in 1998?
Para 5.16-5.17
Firstly, who will be the commissioners of social
care services? Secondly, SSDs have been actively considering the
needs of people living with HIV in other relevant services since
the advent of the NHS and Community Care Act (1990).
QUESTIONS
The answer to both of these is yes, because the proposed
principles for commissioning sexual health and HIV services are
already happening and the multi-agency commissioning groups are
already a part of local partnership groups. As stated above these
have been so for some considerable time, having to cope with constant
change of titles and terms of reference.
ACTIONS AND
TARGETS
Plans—This statement
provided members with yet again a sense of deja vu, multi-agency
plans were first created as part of the NHS and Community Care
Act (1990) process across specific client groups, including HIV.
SECTION 6
Para 6.1-6.8
The strategy document we were expecting following
numerous meetings and consultation exercises was one that would
provide clear guidance as to the way forward and not one of repeating
processes of research that have already been carried out at great
expense. Surely, once again, this should be about building on
that work.
Para 6.9-6.12
We whole-heartedly endorse the commitment to education
and training. As the English National Board for Nurse education
is being disbanded in 2002, the SIG recommend that the government
actively look at how nurse and allied professionals will receive
a specific accredited course for those involved in the care and
support of people living with and/or affected by HIV, as a replacement
for the current ENB 934.
Para 6.14
Members were very concerned to see that the emphasis
here is on medical models and makes no reference to social models.
Social care is constantly sidelined in the document. We have said
that the Strategy needs to include "joined up" management
of HIV/AIDS with other Government departments such as the Home
Office and DfES: HIV impacts education, employment and benefits,
immigration and asylum, international development, etc. We have
said that HIV is not just another STI and great concerns surround
the aims to mainstream HIV within general sexual health care.
Clinically HIV demands long-term, specialist treatment. Socially
it raises issues above and beyond sexual health and it remains
a source of stigma and discrimination.
Para 6.15-6.17
The members were in agreement with the statement
about considerable modernisation and expansion of the human resources.
However, concern was raised at the constant use of the term "health
care professionals" and raised questions as to whether this
also includes Social Work and Social Care staff.
QUESTIONS
—Research priorities—Whatever research
can be funded, provided it builds on previous research can only
be for the good. What service users and providers don't want to
see is expensive and meaningless research.
—Access to and quality of services—The
only way in which this can be maintained after the allcoated
monies are added to health authorities' (or those that are left)
main allocation is to provide strict criteria as to how the money
can be used. Over the last seven to eight years we have seen the
demise of funded staff and voluntary sector agencies due to the
money being directed elsewhere.
—HIV prevention—by ensuring that
money allcoated for prevention is spent on prevention activities.
SECTION 7
The implementation of this strategy can only aim
to promote the reduction of stigma as part of a whole process.
The implementation of the strategy itself will not reduce stigma
assoicated with HIV and other STIs.
SIG CONCLUSION
The members' overwhelming response to this strategy
document was one of open-ended promises without concrete policy
and procedure. We were under the impression that the research
and consultation exercises had been conducted to give concrete
aims and outcomes in the strategy not to be the starting point.
The strategy does not give baselines for agencies that are expected
to plan, review, monitor and evaluate against targets and outcomes,
again it appears to be a case of one strategic framework being
written in isolation and not "joined up" with associated
or linked documents apart from in passing reference. Surely the
right place to start with this strategy would have been an opening
statement to say that the aim of this document would be to build
upon and extend the work that has gone before it, since 1990.
28 All-Party Parliamentary Group on AIDS (2002),
Response to the Department of Health National Strategy for Sexual
Health and HIV, APPGA. London. Back
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