Equally Safe consultation: analysis of responses

6. Potential impacts of the proposals 

6.1. The consultation documented notes the Scottish Government’s intention ‘to carry out a Data Protection Impact Assessment and a Child Rights and Wellbeing Impact Assessment in the wider context of a human-rights based approach to the development of legislation’. It explains that an Equality Impact Assessment, a Fairer Scotland Assessment, and an Islands Impact Assessment will also be carried out.

6.2. Respondents were invited to identify any potential impacts, and to share views in relation to equalities and costs. This chapter presents an analysis of those responses.

Responses to question nine: Equality Impact Assessment

Question 9: Do you have any views on potential impacts of the proposals in this paper on equalities (the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation)?    

6.3. A quantitative overview of responses to this question is provided below:

• 51% (27 out of 53) selected ‘yes’ 
• 23% (12 out of 53) selected ‘no’
• 8% (4 out of 53) selected ‘don’t know’
• 19% (10 out of 53) did not answer the question

Overview

6.4. Just over half of the consultation respondents (32 out of 53) provided a comment on potential impacts in relation to equality. Of these: 

• Twenty-three respondents reflected on implications for equality in some detail. These responses often described a particular issue for the Scottish Government to consider when developing the legislation, or other opportunities to enhance equality impacts.
• Seven endorsed the proposals outlined in the consultation document without further suggestion. Their comments conveyed a view that the Government’s intentions will achieve a positive impact in relation to equality.
• Two provided general comments which did not convey a view on any potential impacts.

6.5. A number of themes were evident with the responses. Common discussion points included reflections on the value of an Equality Impact Assessment (EQIA), the potential for service improvements, experiences of specific groups, views on self-referral, access to female examiners, staff training, confidentiality, and consent.  Each theme is discussed in more detail below, presented in order of prevalence, from the issues discussed most frequently to one-off comments.

Comments on the Scottish Government’s proposal to conduct an Equality Impact Assessment 

6.6. The most frequent theme in comments, identified in eighteen responses, was some form of endorsement of the Scottish Government’s decision to undertake an EQIA. Within these comments, four respondents suggested they did not believe anything put forward in the consultation document would have an adverse impact on equality. 

6.7. A range of benefits were identified in relation to undertaking the EQIA, including enhanced understanding of specific needs of groups with protected characteristics; and the value of assessing how the proposed services will contribute to the Equality Duty. 

6.8. Other respondents highlighted positive impacts stemming from the implementation of the legislation, such as improving the equity of experiences for groups with specific needs or addressing an existing inequality, by focusing on women who are disproportionally impacted by rape and sexual assault. 

6.9. However, one respondent suggested that the EQIA should have been undertaken already; they urged the Scottish Government to publish the assessment ahead of any draft legislation. One suggested that greater consideration should be given to people with profound and multiple learning difficulties.  Another suggested that there may be unanticipated impacts of the approach but did not expand on this comment to suggest what these might be. 

6.10. When discussing equality one respondent suggested that the legislation should consider the role of decision-making proxies and signposted the Scottish Government to existing guidance. 

Service design 

6.11. The second most common theme concerned equality impacts in relation to different aspects of service design and provision. This was mentioned by twelve respondents, whose comments centred on: 

• Provision of services and processes which offer victims control and choice.
• Effective communication, including accessible information available in a range of formats.
• Permitting the presence of an advocate or other support worker during an examination, if desired by the victim. Within these discussions were references to the CRPD and The Mental Health (Care and Treatment) (Scotland) Act 2003.
• Linked to the point above, for services to recognise the role of advocates in providing support and facilitating informed decision-making and support prior and post to forensic examination.
• For services to tackle barriers to access, for example by providing interpretation services.
• A need for victims to access services locally.
• To create sufficient capacity within services to meet the specialist needs of groups with protected characteristics, or those in rural areas (discussed in more detail below). Suggestions in this vein included the potential role of the forensic nurse examiner. A small number highlighted the need for appropriate equipment and examination settings.

6.12. One respondent suggested that best practice guidelines and ring-fenced funding would be crucial for meeting the aims of the legislation.

Equality impacts on vulnerable groups

6.13. Nine respondents commented on the equality impacts of the proposals in relation to vulnerable groups. Many of these responses focused on service delivery considerations, linking to the comments described above.

6.14. One respondent suggested that improved patient access, including self-referral routes, would reduce health inequalities among groups with protected characteristics as well as men and boys who experience sexual assault.  Another highlighted that greater engagement with FMS would improve access to justice, and for the rights of vulnerable and minority groups to be enacted.

6.15. One highlighted the importance of local access to FMS as a key factor to enable self-referral for people with disabilities, who may face additional mobility barriers.

6.16. It was also highlighted that particularly at-risk groups, for example, people who are trafficked, are more likely to access health service than engage with criminal justice agencies. 

6.17. One expressed a concern that people with learning disabilities will not be treated equally within due to other laws in place, citing the Adults With Incapacity (Scotland) Act 2000 as an example.

Training

6.18. Interlinked with discussions about services, the importance of staff training was raised in eight responses. In these comments respondents reflected on the importance of developing an understanding among forensic medical practitioners about the needs, experiences and challenges experienced by specific groups.

6.19. Themes in training in relation to supporting vulnerable adults included: appropriate communication skills; not patronising adults with learning disabilities; and understanding sexual relationships.

6.20. Respondents who commented on training gaps also highlighted the need for LGBTI awareness and wider training to overcome prejudice and assumptions about people from minority ethnic communities, sex workers, human trafficking victims and victims of female genital mutilation. 

LGBTI community

6.21. Seven respondents commented on the proposed legislation in relation to its impact on LGBTI people. General comments about the importance of training for staff about the needs and experiences of this community were the focus of many of these comments. 

6.22. One respondent suggested the consultation document had not considered transgender women victims of male or transmale rape. Another described specific barriers to reporting experienced by male, gay, transgender and intersex victims and urged the Scottish Government to focus on addressing these issues. 

6.23. In noting the underreported rates of sexual violence experienced by the LGBTI community, one highlighted their expectation that the trauma-informed approach to FMS would lead to increased engagement with health care and justice agencies by victims.

Female examiners

6.24. Six respondents commented on the importance of access to female examiners in relation to equality. One suggested that provision of a male examiner was also a consideration, stating: ‘LGBTI survivors however, may prefer a male examiner for various reasons relating to their own sexual orientation or gender identity, and/or the gender of the perpetrator. This may be particularly pertinent for gay and bisexual men, trans people, and intersex people/ people with variations of sex characteristics (VSCs)’. Another emphasised that this provision should be explicitly extended to those who make a self-referral. 

Children and young people

6.25. Four respondents reflected on the Equality Impact Assessment in relation to children and young people. One called for clarity in the age criteria for self-referral.  Another reflected on the need for appropriate education for children and young people about consent and relationships. 

6.26. One organisation highlighted the need for a different approach to ensuing appropriate services are available for children and young people. They noted that this group, by virtue of their protected characteristic of age, will require specific support.

6.27. In discussion about improved patient access, a respondent suggested that provision of NHS self-referral routes would also encourage young people to engage with trauma-informed support, who might otherwise be reluctant to go to the police.

Support for men and boys

6.28. Four respondents reflected on the Equality Impact Assessment in relation to men and boys. They highlighted the need to reduce access barriers to trauma-informed services and called for the provision of support and psychological services for men and boys.

Consent 

6.29. Consent was mentioned in four responses. One respondent noted that consideration within the legislation and provision of safeguards were needed if an individual’s ability to consent to a forensic medical examination is absent or impaired. Another highlighted that victims should be made aware that they have the right to withdraw their consent at any time in the forensic examination process.

6.30. As described above, the issue of consent in relation to sexual activity was also raised by one person who reflected on the need for appropriate education about consent within sexual relationships. 

Implications for those in rural areas

6.31. Notwithstanding responses to the question 11, which asks specifically for views on impact in relation to people in rural or island communities, two respondents referenced rural areas in their response to the Equality Impact Assessment. One highlighted significant delays and travel burdens for victims from rural areas in the current system. The other suggested that local delivery models may not have the capacity to provide specialist care.

Evidence from the lived experience

6.32. One respondent suggested evidence from the lived experiences of victims should be included in the Equality Impact Assessment process.  Linked to this, another said that more broadly, the lived experience should inform further development of the legislation.

Other comments and examples

6.33. Three respondents shared comments that fall outwith the discussion themes described above. These are summarised in Appendix 5.

A sample of illustrative quotes that typify the themes identified in this section:

“These proposals will have positive impacts on women who are disproportionately impacted by rape and sexual assault.” (NHS Highland)

“Important to emphasise these aspects since people from ethnic minorities, vulnerable adults (especially those with a learning disability), sex workers or LGBT people may be subject to prejudice and assumptions about lifestyles which lead to a lesser service.” (Individual, anonymous)

“We welcome the Scottish Government proposals and we think they improve the access to forensic examinations and other health services for victims of rape and sexual abuse. We think it is a positive thing that people will be given access to forensic examinations and medical support at self-referral level. Like all people, we should be encouraged to report a crime, and get the support we need to make an informed decision about this.”  (Organisation, anonymous)

“There are specific barriers to reporting for male, gay, transgender and intersex victims and therefore any legislative reform should have a focus on improving service provision and preventing further barriers.   Forensic examination facilities and associated arrangements should not further prohibit or discourage individuals from seeking medical assistance.” (Organisation, anonymous)

Responses to question ten: Socio-Economic Equality Impact Assessment (the Fairer Scotland Duty)

Question 10: Do you have any views on potential impacts of the proposals in this paper on socio-economic equality (the Fairer Scotland Duty)? 

6.34. A quantitative overview of responses to this question is provided below:

• 17% (9 out of 53) selected ‘yes’
• 59% (26 out of 53) selected ‘no’
• 4% (2 out of 53) selected ‘don’t know’
• 30% (16 out of 53) did not answer the question

Overview

6.35. Almost one-fifth of the consultation respondents (11 out of 53) commented on potential impacts in relation to socio-economic equality. Of these: 

• Six respondents discussed the implications for socio-economic equality.
• Four endorsed the proposals outlined in the consultation document without further suggestion. Their comments conveyed a view that the Government’s intentions will achieve a positive impact in relation to socio-economic equality.
• One shared a general observation which did not convey a clear view.

The impact assessment process

6.36. Two respondents suggested that socio-economic equality should be incorporated within the Equality Impact Assessment, with one of these calling for the Duty to extend beyond health boards to all services involved in any linked processes. 

6.37. Another respondent suggested that any public bodies referred to in the Fairer Scotland Duty should be made aware of their duty in the planning process and one made a general statement of support for the proposal to carry out a Fairer Scotland assessment.

Equity of access

6.38. Two respondents noted that enhancements to legislation or services would improve access for all, including those at a socio-economic disadvantage. In the discussion about equity of access, one respondent raised the issue of appropriate communication and language to enable engagement with FMS.

Other views

6.39. Singular other comments given in response to this question are listed in Appendix 5.

A sample of illustrative quotes that typify the themes identified in this section:

“Providing services more locally can only improve access for all regardless of socio-economic circumstances.” (Individual, anonymous)

“Police Scotland supports any legislative enhancements which promote consistent service delivery across all communities of Scotland.” (Police Scotland)

Responses to question eleven: impacts for people in rural or island communities

Question 11: Do you have any views on potential impacts of the proposals in the Chapters of this paper on people in rural or island communities? 

6.40. A quantitative overview of responses to this question is provided below:

• 55% (29 out of 53) selected ‘yes’
• 15% (8 out of 53) selected ‘no’
• 8% (4 out of 53) selected ‘don’t know’
• 23% (12 out of 53) did not answer the question

Overview

6.41. Almost two-thirds of the consultation respondents (32 out of 53) commented on potential impacts in relation to people in rural or island communities.  In these responses:

• Twelve respondents focused on the impact of the proposals for people in rural or island areas; almost all identified a positive impact.
• Eleven identified challenges associated delivering forensic medical services in rural or island areas, and within these comments, many shared views on how these might be overcome.
• Six respondents comments’ combined discussion on positive impacts and challenges of delivering services.
• Three provided general comments that did not convey a clear view.

6.42. A number of cross-cutting themes were evident in the discussion on benefits and challenges outlined above. These included:

• Movement of staff to rural areas
• Potential service improvements
• The role of legislation
• Travel by people from rural and island communities
• Impacts for minority communities and children and young people

6.43. Each of the themes above is described in the remainder of this chapter.

Impacts of the proposals

6.44. There were two key themes in the discussion of impacts of the proposals for people in people in rural or island areas. Firstly, respondents welcomed greater equity of access to FMS. Secondly, they identified other positive impacts of resulting from changes to service design and provision.

6.45. Greater equity of provision was anticipated by five respondents. In these comments four specifically referred to a ‘postcode lottery’ of access to specialist support, depending on location. Respondents highlighted the importance of local availability of services as important to a victim-centred delivery; one commented on local access as significant for a child-centred approach. 

6.46. Other positive impacts resulting from the proposals included reduced delays, limiting the distress associated with travel after experiencing sexual violence, helping to normalise the provision of services in rural and remote areas, and development of increased knowledge and experience among local providers.

6.47. Two respondents highlighted the challenge of maintaining confidentiality within small communities and suggested that people might not wish to access local FMS for fear of their attacker being known to staff.

Challenges

6.48. Several themes were evident in the discussion of the challenges of delivering FMS for people in people in rural or island areas. These included service design and resourcing. 

Service design and resourcing

6.49. Most common was discussion of resource implications, raised by seventeen respondents. This included comments on the expense of providing local capacity with references to the specialist expertise and facilities required and in particular the recruitment and retention of staff to fulfil these roles. One respondent called for an audit of sites and personnel, in order to inform planning. 

Travel

6.50. Nine respondents reflected on travel to access services. Views were mixed; some felt strongly that that victims should not have to travel, sharing examples of lengthy journeys undertaken by women and children victims from island communities. Others suggested travel would be necessary, for example to provide choice and access to specialist support. 

Models of delivery

6.51. Various outreach models were suggested by five respondents.  For example, one reflected on the potential of a network approach to provide swift access and flexible services. The others described regional centres or a central hub with outreach facilities.

6.52. Two respondents highlighted the potential for telemedicine systems to play a role within service provision, for example ‘to help facilitate interpretation of injuries by centres of excellence from afar’.

Compromise

6.53. Three respondents suggested that a spirit of compromise might be required to reflect the challenges of delivering services in rural areas; one noted that modification of expectation for those in remote places might be required. 

A sample of illustrative quotes that typify the themes identified in this section:

“Victims’ rights should be respected and they should get the same standardised services wherever they live. For GG&C there are parts of the former Argyll & Clyde that would fall into this category.  Likely to be significant resource implications to ensure availability of standardised services country wide.” (NHS Greater Glasgow and Clyde and Glasgow HSCP)

“Access to this highly specialist service in remote and rural communities where recruitment and retention is an issue presents significant challenges. The possible development of a network approach might be helpful and consideration of how legislation might ensure swift access to high quality services whilst taking account of the need for flexibility in some areas.”  (Organisation, anonymous)

“Ensuring the local availability of forensic examinations and related services across the geography of Scotland is vital to a child-centred approach. The shortages in paediatrician availability locally can result in lengthy journeys and delays “(Children 1st)

“This may help to normalise the necessity for practitioners to be available in remote and rural areas to protect the rights of individuals who live there, including privacy, but in particular person-centred care.” (Individual, anonymous)

Responses to question 12: views on financial implications

Question 12: Do you have any views on the financial implications of the proposals in this consultation paper for NHS Scotland and other bodies? 

6.54. A quantitative overview of responses to this question is provided below:

• 47% (25 out of 53) selected ‘yes’
• 23% (12 out of 53) selected ‘no’
• 6% (3 out of 53) selected ‘don’t know’
• 25% (13 out of 53) did not answer the question

Overview

6.55. Almost half of the consultation respondents (26 out of 53) commented on the potential cost implications of the proposals. A number of themes were identified in these comments: 

• Fourteen provided detail about cost implications
• Eleven shared a general comment of the likely scale of costs
• Six made suggestions about models of service delivery
• Four highlighted other issues to consider when reflecting on costs.

Cost implications

6.56. Fourteen respondents identified specific types of costs associated with the proposals. Provision for training and sufficient staff capacity was raised by six respondents. The costs of premises and equipment was noted by six respondents. Five respondents highlighted the need to fund wider services that play a role in trauma-informed recovery, including ongoing counselling for victims, or support for family members.  

The scale of costs

6.57. There were eleven comments about the scale of costs associated with the Scottish Government’s proposals.  Many of these were non-specific, such as ‘ambition requires money’ or ‘there will be resource implications’.

6.58. Four respondents reflected on the competition for resources among health and social care service providers. Linked to this, when discussing budgets, one respondent called for central ring-fencing of resources specifically for FMS. 

6.59. Three respondents called for the Scottish Government to undertake a financial appraisal to inform decisions about resource allocation. Two of these suggested that the proposed changes are likely to result in an increase in self-referrals, noting that increased demand should be factored into budgets and capacity planning. 

6.60. Another acknowledged the scale of start-up costs for new FMS but called for recognition that this could lead to greater savings in the longer term, for example due to faster recovery and improved mental health outcomes.

Delivery models

6.61. Reflections on delivery models were also evident in any discussion of costs.  Six respondents commented on this theme, with varied suggestions evidenced in these responses, which are available in Appendix 5.

Other views

6.62. One respondent suggested that the Scottish Government consider a joint commissioning model, which could open up service provision to other suppliers.

6.63. Another called for the Scottish Government to consider the impact on legal aid with regard to the provision of legal advice and assistance. They highlighted potential challenges to how forensic samples have been obtained. The possibility for legal advice in civil cases where a damages action is brought against a person who has been acquitted of an alleged rape was also raised.

6.64. One suggested that services for adolescents and men should be separately funded.

6.65. One expressed a fear that forensic medical examination more widely may limit the development of the Scottish Barnahus model or prevent access to it, but did not explain why.

A sample of illustrative quotes that typify the themes identified in this section:

“In order to meet the Standards in relation to both gender choice and timeous access, there is a need to increase both the female FME workforce and nursing workforce in terms of chaperones.  This comes with an increased financial resource requirement, which as it stands is a risk with competing financial priorities for Boards who are already under pressure.” (NHS Ayrshire and Arran)

“Ambition requires money, to meet the objectives of this paper there must be significant additional resource allocated.” (Rape Crisis Scotland)

“Should the retention of samples in self-referral become a responsibility of the Health Boards, investment will be required.  A workforce will be required to be developed and recurrently resourced to achieve and maintain the skills required to provide assurance to the Judiciary concerning the veracity of stored samples.  Purpose built or refurbished facilities for the storage of samples will require capital investment.” (Organisation, anonymous)

“The number of victims likely to seek the range of medical provision as proposed in the consultation paper is unclear, and this is particularly true of respect of self-referral cases.  However, there should be a focus on encouraging victims to seek medical assistance, whether that includes a forensic medical examination or not, or whether that forensic medical examination relates to a police case or a self-referral.  That being the case, it is reasonable to assess that the number of cases will increase from current and recent levels.  There will therefore be an associated cost in respect of consumables as well as practical arrangements in respect of the appropriate storage and retention of samples.” (Organisation, anonymous)