Reset and Rebuild - sexual health and blood borne virus services: recovery plan

Towards recovery

As the previous sections show, the scale of the challenge in the last year has been matched only by the scale of change it has occasioned. Both have occurred at unprecedented speed, and there has been little time to fully understand the impacts of either. The actions in this section set out to change that, and in so doing, to rebuild services that retain the best of the COVID response; are resilient to future shocks; and remain able to provide the vital services we rely on to prevent, diagnose and treat BBVs and STIs.

Service users must be at the heart of this work, and we must recognise and support the role that research and evaluation will play in ensuring that ongoing innovations and care pathways are evidence-based. Above all, we must enable services that can assess and treat those in most need if we are to progress the ambitions of the SHBBV Framework and its outcomes - offering services that empower and support people to live happy, fulfilled and healthy lives.

Achieving this will not be easy. Sexual health and blood borne virus services will be subject to pressures common across all services, and, while the impact of COVID-19 was immediate, there are no instant solutions that will bring about service and population recovery. Indeed, to some extent, efforts will hinge on the continued success of vaccines to tackle the pandemic, and the ability of the wider healthcare service to remobilise and rebuild. However, below, we have set out a series of actions that are intended to demonstrate the Scottish Government's on-going commitment to and support for SHBBV services, and to put them on the best possible footing to recover as time and conditions allow.

In some instances, progress will be directly accountable to specific groups, such as the Scottish Health Protection Network Hepatitis C Elimination Group, but in general, progress of the whole plan will be monitored by and reported to the Scottish Health Protection Network Strategic Leads. This reflects our commitment to working collaboratively across the range of interests in SHBBV services to build solutions.

As set out throughout this plan, we will prioritise recovering services, patient-centred care and treatment, research and evaluation, and laying the groundwork for a better future. This plan is also one part of wider efforts. In the coming year and beyond, it must support and complement other vital associated priorities, such as the Women's Health Plan, Health Care Improvement Scotland Sexual Health Standards, and the recommendations from the study of young people's use and non-use of condoms and contraception^[12]. It must also support longer term aims, such as the elimination of Hepatitis C by 2024 and our ambition to eliminate HIV transmission by 2030.

Below, the actions have been subdivided for ease; however, we recognise that in the real world, there will be no such division, and that they are all linked – building for the future, for example, will not be possible without robust evaluation, and recovery of services will be enabled by changes to treatment that increase the capacity of clinicians and third sector workers. Finally, the actions do not constitute all that will be done in the coming year – we will remain flexible and open to responding to new priorities as circumstances dictate. However, we hope they will lay strong foundations on which to build.

Actions - Recovering services

Action 1: the Scottish Government will provide third sector delivery organisations with £0.8 million of funding in 2021/22

In recognition that the end of the current multiyear Framework has impacted on third sector organisations, we have provided funding as an interim measure for 2021/22 for those organisations that were funded under the previous settlement. This funding will support both recovery priorities and the ongoing Framework outcomes, and ensure that third sector organisations can continue to provide the vital services that have supported users both over the last decade and during the pandemic.

Action 2: the Scottish Government will make additional funding available to support recovery actions

The work of recovery may require additional funding to be shared by clinical, academic and third sector projects, recognising particularly that SHBBV services also have a role in teaching, training, and providing expertise for evaluation and policy development. The Scottish Government will therefore provide additional funding over the course of the year that will support specific recovery actions, particularly those focussed on testing, HIV and Hepatitis C elimination. Allocation of this funding will be determined collaboratively with key stakeholders and partners.

Patient centred treatment and care

In 2021/22, we will continue to focus on new models of treatment, building on the successes of the pandemic response, ensuring that patients receive treatment when and how they need it, and freeing up staff capacity by removing face-to-face contact where it is not clinically necessary or desired by the patient. The following actions will help to support this.

Action 3: the Scottish Government will continue to support online testing

In late 2020, the Scottish Government provided just over £375,000 to support an online testing solution to develop a national 'Once for Scotland' online service for sexually transmitted infections and blood borne viruses. This allows service users to request testing online, enabling them to take their own samples at home and return to the laboratory for results. As well as increasing access for those who are geographically distant from physical services, work will continue to ensure this service widens access for groups who are traditionally harder to reach, while freeing up capacity of staff for those for whom in-person support remains the best option. The solution will also support national anonymised HIV intelligence systems to provide comprehensive, real time data on HIV care and outcomes locally and to Public Health Scotland.

In recognition of current capacity challenges for HIV testing within healthcare settings, and the increased role of remote testing, as an interim measure in 2021-22, the Scottish Government has also provided funding to expand the use of HIV self-testing. In conjunction with self-sampling, evaluation of HIV self-testing will form part of a more wide-ranging review of the testing landscape in Scotland, with a focus on inequalities and access as well as swift access to support and to care pathways.

Action 4: Community Pharmacies will be supported to provide the progestogen-only contraceptive pill

From September 2021, all community pharmacies will be able to provide a temporary three month supply of the progestogen-only contraceptive pill. This will be implemented through the national community pharmacy contract arrangements and Pharmacy colleagues are working in partnership with Community Pharmacy Scotland on the arrangements. Service specification and training are being developed with input from Health Boards, sexual health leads and Community Pharmacy Scotland as part of the Community Pharmacy Contraception Working Group. Building on this will be the incremental development of an enhanced women's sexual health service in community pharmacies to provide pre-conception, menopause and abortion support.

Action 5: NHS Scotland will widen access to HIV pre-exposure prophylaxis (PrEP)

The NHS Scotland HIV pre-exposure prophylaxis programme was launched in 2017 and has contributed to HIV diagnoses among men who have sex with men in Scotland declining by 20% between the two years before and two years after implementation of PrEP. Recently acquired infections declined by just over one third^[13]. However, to further reduce the incidence of newly diagnosed HIV infections, access to PrEP now needs to be widened^[14] to enable its benefits to extend to a much wider range of people, including those who do not access sexual health services. To do this, novel models of care will be required and PrEP will need to be provided in additional settings which people from groups not currently accessing PrEP find acceptable.

Remote self-managed care, including postal self-sampling for HIV & STIs combined with an online automated consultation and prescribing pathway, will be considered for routine monitoring and prescribing for people already established on PrEP. Research from Glasgow Caledonian University is being used to develop a prototype "ePrEP clinic" to enable this. This would allow people to meet their PrEP needs easily and conveniently whilst freeing up clinic capacity for those with more complex PrEP needs. It is hoped this could also reduce barriers to accessing PrEP due to its discreet nature.

Action 6: NHS Boards will work to re-establish HCV treatment to meet the goal of elimination in 2024.

Treatment targets for HCV were suspended from March 2020, and work was undertaken to understand how these could best be re-instated. Aided by recommendations developed by the SHPN Hepatitis C Elimination Group, a treatment target of 2000 patients for 21/22 has been agreed. This will be a vital first step in re-energising work to eliminate HCV by 2024. As resources allow, it will be supplemented by concerted effort to adapt outreach and treatment methods. In particular, the SHPN Hepatitis C Elimination Group will explore how Scotland can scale up treatment numbers, find untreated people and support those with increasingly complex needs to engage in and complete treatment.

The Scottish Government welcomes the set of recommendations recently published from the NIHR-funded EPIToPe project, following their research into the upscaling of HCV treatment amongst PWID. The recommendations made within this manual will be a valuable resource for both policymakers and practitioners working towards the 2024 target.

Research and evaluation

Sustainable recovery will require a dedicated focus on research and evaluation of the impacts of both the pandemic and the service changes that it occasioned. In the coming year, we will work towards a number of projects to understand and put patient needs at the heart of services however they are delivered.

Action 7: The Scottish Government will work with stakeholders to support and develop a number of research projects to understand the impacts of COVID-19 on service users and providers.

In developing these projects, we will recognise the value of academic research, patient voices, and the expertise of clinicians and third sector providers. We will also build on the excellent work that is already underway and rely on existing resources, such as the National Monitoring and Research Group. As standard, evaluation of services will also be embedded into all projects funded by the Scottish Government, and we will explore opportunities for research as they emerge over 2021. At present, we anticipate some key areas of research will include:

• An assessment of the impact of revised models of HIV care through patient outcomes and national data collection, including completion and analysis of the patient satisfaction survey on remote consultations.
• Research investigating the direct impact of COVID-19 and indirect impact regarding risk of BBV and other harms on people who use and inject drugs.
• Evaluation of the use of telephone/video consultation in sexual health services.
• Innovation research and development of novel care models and systems e.g. eHealth solutions.
• Piloting and evaluation of new care pathways e.g. a community-based PrEP service.

Action 8: The Scottish Government will establish a Sexual Health Digital Group

In addition to the specific research projects set out above, there is a need for a more concerted understanding of digital provision in sexual health services. As noted several times throughout this document, digital innovations have been one of the most significant features of the pandemic response. However, as also noted, these are not always suitable for all priority groups in their current form, and the pace of change did not always allow for all systems to catch up or evolve at the same speed. The Group will therefore assess the current digital offering for sexual health services, identifying areas for improvement, either across the whole system or for particular groups, and develop a plan for how innovations during the pandemic can be maintained in a way that continues to support our most vulnerable groups.

Building for the future

Recovery must not only focus on achieving the previous status quo. Too much change has already occurred, and there is too much still to be achieved. Therefore, while our ability to be bold may be more constrained in the coming year, our ambitions for what can be achieved will not. Wherever possible, we will lay the groundwork so that these ambitions can be realised in 2022 and beyond.

Action 9: A Scottish Government-led Short Life Working Group will develop 'Once for Scotland' recommendations on HCV diagnosis and treatment for people who inject drugs.

We have made a commitment in our 2020/21 Programme for Government to work with the Scottish Health Protection Network (SHPN), third sector and people who use services, to understand how best practice and innovative approaches – including that pioneered in NHS Tayside, which resulted in HCV elimination in 2019 – can be replicated across Scotland. The Short-life Working Group will develop practical proposals for a national approach in how PWID are found, treated and diagnosed. This will complement the wider work of the SHPN Hepatitis C Elimination Group.

Action 10: The SHPN Strategic Leads will develop a HIV transmission elimination proposal.

The Scottish Government has commissioned SHPN Strategic leads, working with clinical, academia and third sector partners, to deliver a proposal for how Scotland can be the first country to end HIV transmission. This will be a key element in the Scottish Government's next SHBBV Framework. The proposal will contain advice on definitions, actions, targets and monitoring outcomes, as well as ways to ensure capacity to report timely data.

Action 11: The Scottish Government will evaluate and explore how changes to abortion provision can be embedded into practice post-pandemic

We acknowledge the complexities and sensitivities of this issue. We will therefore work with partners to assess the impact of COVID-19 on how women access abortion care as part of the planned evaluation of the current arrangements for early medical abortion at home. The results of the recent consultation on early medical abortion will also inform our policy going forward.

This will also include further assessment of provision more locally of later stage abortions up to and over 20 weeks gestation.

Conclusion

This plan has been developed to acknowledge the challenges SHBBV services face, but also to celebrate their resilience and capacity for innovation. The Scottish Government again extends its thanks to the staff and service users who responded with creativity and positivity to some of the most challenging times many of us have ever experienced.

The dedication displayed deserves an equal commitment to lasting change and sustainability, and we pledge that we will work with partners to achieve that. While the actions in this plan are only the first step, we look forward to implementing them, and to building towards a Framework in 2022 that will ensure Scotland continues to offer SHBBV services that improve the lives of the people who need them.