Women's health plan 2021 to 2024: final report

Menopause and Menstrual Health, Including Endometriosis

Priority: Improve access to information for girls and women on menstrual health and management options and; Improve access for women to appropriate support, speedy diagnosis and best treatment for endometriosis

Aims:

1. All young people will be aware of normal menstrual health.

2. Average diagnosis time for endometriosis will be reduced.

3. All women will be able to access the right support and effective treatment for endometriosis.

4. When required, all women will have access to a specialist endometriosis centre.

Menstrual Health Network

Building on the success of the Menopause Specialist Network an equivalent network for health care professionals has been established, focussing on menstrual health.

The Scottish National Menstrual Health Specialist Network, chaired by Dr Jackie Maybin, meets quarterly and provides a forum for peer support and sharing expert clinical advice, best practice and innovation across NHS Boards to support healthcare services to be responsive and adaptive to the individual needs of women and girls.

Each meeting includes a spotlight session where clinicians are invited to share their specialist knowledge to support learning and raise awareness of conditions that are often overlooked. Discussions to date have included;

• Adenomyosis
• Polycystic Ovary Syndrome (PCOS)
• Premenstrual Syndrome (PMS) and Pre Menstrual Dysphoric Disorder (PMDD)

PCOS Awareness Month

Scottish Government buildings were lit up on 9th September 2024 as part of a global light up event to raise awareness of the condition.

More information on PCOS can be found on the NHS Inform Women’s Health Platform Polycystic ovary syndrome (PCOS) (nhsinform.scot)

Policy into Practice: NHS Ayrshire and Arran’s multidisciplinary approach to updating pathways for PCOS

“Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age – depending on the study considered it can affect anywhere between 2-26% of women¹. PCOS is normally identified following puberty and symptoms and signs include irregular or absent periods, acne and hirsutism (excessive hair growth)². Those from certain ethnic minority backgrounds including South Asian communities are at increased risk of developing PCOS³. People with PCOS also have an increased risk of diabetes, weight gain and cardiovascular diseases.

Work to develop a cohesive and comprehensive pathway for the diagnosis and management of PCOS in NHS Ayrshire and Arran was started in early 2024. Specialists from gynaecology, fertility, dermatology, endocrinology, diabetes prevention and weight management services, primary care and public health worked alongside the charity PCOS Relief to ensure a patient-centred pathway could be developed that took into account the different needs and goals that PCOS patients may have. The pathway has included a focus on preventive and self-management services that should be integral to every PCOS pathway. Patient focussed information resources were included from a range of trusted sources such as Royal College of Obstetricians and Gynaecologists, NHS Inform, PCOS Relief and Verity.

Recognising that different patients will have different needs and goals was important and this was included in the pathway. Examples include recognising for some that symptom management is the primary goal, where contraceptive medication is often used as a first line treatment, where for others maximising fertility might be the primary goal and early referral to fertility services is important.

Final work is being undertaken on the pathway, with a view to launching this in late 2024, including publishing on the NHS A&A Right Decision Service”.

1. Prevalence | Background information | Polycystic ovary syndrome | CKS | NICE

2. Polycystic ovary syndrome (PCOS) | NHS inform

3. PCOS-Guideline-Summary-2023.pdf (monash.edu) (Page 12)

Short Term Actions

Action: Promote the use of positive language around menstrual health.

NHS Inform Menstrual Health Resource

• In August 2022, a new menstrual health resource was launched on the NHS Inform Women’s Health Platform. The resource includes information on everything from what periods are, choosing period products and what to do if you get a tampon stuck, to common symptoms like period pain and heavy menstrual bleeding; and menstrual health conditions including fibroids, PCOS and endometriosis.

There are three short films which provide information and support from experts on; What’s Normal?, Irregular Periods and Premenstrual Syndrome (PMS). All the films can also be accessed in one place, here.

The resource includes an animation on endometriosis created by Endo Warriors West Lothian with the Excellence in Pelvic Pain and Endometriosis Care and Treatment centre in Edinburgh (EXPPECT). There is also a short animated film, produced by the University of Edinburgh, explaining more about Polycystic Ovary Syndrome (PCOS).

The power of lived experience

For women experiencing a challenging time, it can be extremely helpful to know they are not alone. The NHS Inform menstrual health resource includes videos sharing the lived experience of women with a range of symptoms and conditions to provide this additional support.

This includes a film focussed on living with endometriosis, another on living with adenomyosis produced by the Alliance as well as a short film on heavy menstrual bleeding produced by the red-y to talk project from The University of Edinburgh.

Around one in three people who menstruate develop fibroids at some point in their life and they are more common as you get older. Despite being so common, fibroids are often not talked about. The ALLIANCE produced a short film sharing the personal experience of managing the difficult symptoms of fibroids and the journey to treatment which is also available on NHS Inform to support others who may have similar experiences.

Red-y to Talk – reducing menstrual stigma

The Maybin lab, at the Centre for Reproductive Health at the University of Edinburgh, has developed a brand new women’s health resource which includes a selection of digital stories that have been created to empower women and people who menstruate to share their experiences and reduce menstrual stigma.

This Red-y to talk project includes digital resources, supportive information and details of how to donate to vital women’s health research.

Three short and powerful personal stories (revealing lived experience of problem periods)

Discussing Periods to Reduce Health Inequalities is a collaboration between the Flow Right Patient and Public Involvement group and researchers at the Centre for Reproductive health at the University of Edinburgh.

“Flow Right is a group of people with lived experience of problematic menstrual bleeding who work alongside scientists to design and disseminate research on menstruation.

Find out more and join the group here: Flow Right patient and public involvement group | The University of Edinburgh”

Action: Where appropriate offer women who are eligible for combined hormonal contraception, the option of a continuous or extended regimen and raise awareness of the option of no bleeding, even if contraception is not required.

• Information on the option for no bleeding is provided on NHS Inform, across the menstrual health and contraception content.
• Increasing awareness with women of this option was also raised during the periods and menstrual health webinars hosted by the ALLIANCE. This option was particularly highlighted during the PCOS webinar, which had a focus on how hormonal contraception can help to manage the symptoms of the condition.
• The option of no bleeding, even if contraception is not required, is highlighted within the menstrual health education and training resource developed by NES for general practice and primary care.

Medium Term Actions

Action: Use existing programmes, such as the HPV vaccination programme, to provide general information to young people about periods, menstrual health and management options.

• Online resources about the HPV vaccination programme have been updated to link to the women’s health platform, supporting young people, and their guardians or responsible adults, to access information about periods, menstrual health and much more. In addition, online resources about cervical and breast screening programmes also signpost to the Women’s Health Platform for more information on women’s health topics.
• This is reflected across the Women’s Health Platform which includes information on screening and vaccination programmes across the lifecourse as appropriate, raising awareness about these programmes.
• Public Health Scotland lead the development and provision of non-digital information which supports screening and vaccination programmes. There is a workstream in place, aligning with the timescales for each programme, to ensure that hard copy resources are refreshed to include reference to the women’s health platform on NHS Inform.

Cervical Screening Reminder Postcard

Public Health Scotland has developed A6 postcards to be given to all young people in S1 after they have their HPV vaccine.

The postcard confirms the young person has been given their HPV vaccine.

It also aims to act as a reminder about cervical screening and the importance of making sure everyone is up to date with routine screening appointments to ensure they have the best protection from cervical cancer. It is hoped it will act as a prompt for anyone who may have missed or ignored their last cervical screening invitation and encourage them to book an appointment.

Action: Provide access in each primary care team to a Healthcare Professional (HCP) or HCPs who have a specialist knowledge in menstrual health including awareness of the symptoms of PMS, PMDD, heavy menstrual bleeding, endometriosis and their treatment options.

• In order to support those working in Primary Care to be able to access NHS Scotland training on menstrual health, the Scottish Government commissioned NHS Education for Scotland (NES) to develop education and training on this important topic.

Published on Turas Learn, this educational resource is free to access for anyone working in the NHS in Scotland and is particularly aimed at those working in General Practice.

For more information and to access the module please visit the Women’s Health Hub. A Turas Learn account is required, but the resource is then open access to all.

Action: Implement and raise awareness of i) current national guidelines on endometriosis and ii) develop and implement further pathways for care where these don’t currently exist – for example, endometriosis outside the pelvis.

Endometriosis Pathway

• In January 2023 the Centre for Sustainable Delivery (CfSD) published the Endometriosis Pathway for Scotland.

Adapted from NICE guidance, it provides a streamlined, integrated primary, secondary and tertiary care pathway aimed at providing a holistic approach and timely care for those with endometriosis and endometriosis like symptoms.

The endometriosis pathway is intended to facilitate women’s access to endometriosis diagnosis and care, at all points in their patient journey.

To support the use of the Pathway the Scottish Government has provided funding to the Royal College of General Practice (RCGP) for the development of an education module providing further detail on the diagnosis and management of endometriosis within primary care. Intended for use across the UK, the aim of the module is to reiterate the care pathway through case study examples and provide practitioners with advice and reassurance on when to refer to secondary care.

Endometriosis Masterclass

• In March 2024, NHS NES hosted a Women’s Health Masterclass focussed on endometriosis. The Masterclass provided information on diagnosis, treatment and current research on endometriosis, raising awareness of the Pathway with attendees.

You can access the resources here.

New resources for people living with endometriosis

In August 2023, the Scottish Government provided £24,000 of funding to Endometriosis UK to deliver a project creating new resources to support people with endometriosis.

To inform the resources, Endometriosis UK engaged with those living with endometriosis in Scotland through surveys and focus groups. The charity then created a booklet on treatments and self-management tips for managing endometriosis pain, which was published on 3 September 2024. These resources aim to enable those living with the condition to feel informed about the treatment and management of endometriosis associated pain.

In addition to the booklet, Endometriosis UK also produced two webinars on practical and multi-disciplinary pain management. Delivered by medical professionals, such as clinicians, specialist nurses and physiotherapists, these resources are available online to view at Endometriosis UK:

Endometriosis and practical pain management

Endometriosis and pain management from an MDT

Action: Commission endometriosis research to find the cause of the condition, leading to the development of better treatment and management options, and a cure.

In 2022, the Scottish Government collaborated with Wellbeing of Women on a £250,000 research call to commission Scottish research on endometriosis.

The research grant was awarded in March 2023 to the University of Edinburgh, with the funding covering a period of three years, from financial year 2022/23. This funding is supporting the EPiC2 project, which will be primarily run by the EXPPECT team at the University of Edinburgh.

The EPiC2 research is a randomised, double-blind, placebo-controlled feasibility trial involving 100 women receiving care for endometriosis to evaluate the drug dichloroacetate in the management of endometriosis-associated pain.

The data from this research will help to plan a future large scale, UK-wide trial.

In January 2023, the Chief Scientist Office announced funding of £299,509 for the 30 month ENDOCAN project, led by researchers at The University of Edinburgh.

Through a large scale UK-wide trial, the research will investigate whether a cannabinoid can safely reduce endometriosis-associated pain.

Long Term Actions

Action: Strengthen collaborative working between regional specialist endometriosis centres, territorial and special NHS boards and primary care providers, to drive improvement in patient pathways and achieve equitable access to care and treatment.

The Endometriosis Pathway for Scotland, adapted from NICE guidance, provides a streamlined integrated primary, secondary and tertiary care pathway aimed at providing a holistic approach and timely care for those with endometriosis and endometriosis-like symptoms. The endometriosis pathway is intended to facilitate women’s access to endometriosis diagnosis and care, at all points in their patient journey.

Endometriosis Specialist Centre Aberdeen

The Minister for Public Health and Women’s Health, Jenni Minto MSP, travelled to NHS Grampian to hear more about the work of the endometriosis specialist centre and how the pathway through primary, secondary and tertiary care works in practice.

The Minister had the opportunity to hear from staff at the centre, and across the health board, who are passionate about supporting women who live with this challenging condition to access high quality care.

Priority: Ensure women who need it have access to specialist menopause services for advice and support on diagnosis and management of the menopause

Aims:

1. When required, all women will have timely access to menopause support and services.

2. Healthcare professionals will be aware of the impact medical or surgical treatment to induce menopause will have on subsequent health.

3. All women will have access to a healthcare professional with an interest in menopause through primary care.

Short Term Actions

Action: Develop, maintain and promote a support network for Menopause Specialists throughout Scotland. Each healthcare professional (HCP) with special interest in menopause should have access to at least one Menopause Specialist for advice, support, onward referral and leadership of multidisciplinary education.

• The National Menopause Specialists Network, chaired by Dr Heather Currie, meets on a quarterly basis.

The network provides peer support to clinicians across primary and secondary care with a special interest in menopause, and is a forum for sharing current issues, advice and good practice. In doing so it encourages consistency of menopause advice which can then be shared with primary care teams.

Dr Heather Currie, Consultant Gynaecologist and Network Chair, reflects here on the past three years;

“It has been a privilege to be involved with the implementation of the Women’s Health Plan, through chairing the Menopause Specialist Network and the Menopause Clinical Reference Group. These clinical groups have enabled us to highlight issues of concern, share examples of good practice and provide peer support. Outwith virtual meetings, virtual discussions offer menopause advice and suggestions for complex clinical situations.

Many education sessions for healthcare professionals continue to be provided through virtual meetings, weekly drop-in sessions held in some Boards and sharing of resources across our clinical networks.

In recent years we have witnessed a massive increase in awareness, acceptance of and interest in menopause. While this is to be welcomed, we must be aware of misinformation which is present, particularly on social media platforms. It is therefore essential that we continue to educate and support women and healthcare professionals. The various aspects of the Women’s Health Plan provide ideal opportunities to do so.”

Improving information for women

The Women’s Health Platform on NHS Inform includes a comprehensive menopause resource with accessible information and videos on menopause symptoms, options for care, treatment and support, mental health and much more.

There is a menopause symptom questionnaire available on NHS Inform to support women record their menopause symptoms and help facilitate a discussion with their doctor.

The recordings of the menopause webinar series delivered by in partnership with the Health and Social Care Alliance Scotland can be accessed online here.

Action: Provide a holistic approach to care by promoting greater joint working between healthcare professionals on menopause diagnosis and treatment across primary and secondary care and specialist clinics, including through joint education sessions starting with pre and post qualification training on gynaecology.

• Examples of holistic practice are regularly shared by clinicians at the National Menopause Specialist Network meetings to promote better joined-up working across primary and secondary care, and between other specialities.

Spotlight sessions have taken placed at the Network’s meetings including presentations on group consultations and the use of Near Me to facilitate menopause care; case study of the Medlink facilitated medication review for hormonal replacement therapy patients; and a session on the risk factors related to cardiovascular disease and spontaneous coronary artery dissection (SCAD) following menopause.

As part of their role, Menopause specialists continue to deliver local menopause training and drop-in sessions to support primary care with the provision of menopause care.

• The Menopause Clinical Reference Group has been exploring a more holistic approach to menopause care and opportunities for intervention.

This has included work to improve prescribing practice for testosterone for menopausal women; support for women with treatment induced menopause; menopause care for women with cardiovascular disease and promoting the British Menopause Society’s tool for clinicians on the prescribing of hormonal replacement therapy after myocardial infarction through local clinical networks.

• The Clinical Reference Group have been working to promote the British Menopause Society guidance on the Management of Unscheduled Bleeding on Hormone Replacement Therapy across local clinical networks in Scotland.
• NHS Education Scotland (NES) hosted a webinar for healthcare professionals on the menopause as part of their Women’s Health Masterclass series.
• Education sessions have also been held with Scottish gynaecology trainees on menopause. The session held in September 2022 was recorded so that the resource can be accessed by other trainees so they too can ‘think menopause’.

Although a short term action, increasing holistic care in menopause will be an ongoing piece of work.

Menopause support at Maggie’s Centre, Edinburgh

In April 2024, the Minister for Public Health and Women’s Health, Jenni Minto MSP, had the opportunity to visit the Edinburgh Maggie’s Centre based at the Western General Hospital and hear about the ‘Conversations about the Menopause’ workshop hosted for women experiencing treatment-induced menopause.

During the visit the Minister met with a small group of women who had recently participated in the menopause workshop and heard first-hand about their personal experiences of going through treatment-induced menopause and the aspects of support that could be improved for women to better manage their menopausal symptoms through their cancer treatment journey. A discussion was also had with clinical staff at the Western General Hospital on local initiatives happening to support women going through treatment-induced menopause.

We are so grateful to the women for so generously sharing their stories and to the Maggie’s Centre for enabling us to hear them.

Action: Establish a dedicated menopause policy post within Scottish Government.

• A dedicated menopause post was established in the Scottish Government in April 2021.

Medium Term Actions

Action: Provide access in each primary care team to a Healthcare Professional (HCP) who has a special interest in menopause.

• In order to support those working in Primary Care to be able to access NHS Scotland training on menopause, the Scottish Government commissioned NHS Education for Scotland (NES) to develop education and training on this important topic.

The resource is free to access for anyone working in the NHS in Scotland but is particularly aimed at those working in General Practice.

The menopause resource will be available on the Women’s Health Hub in Autumn 2024. A Turas Learn account is required, but the resource is then open access to all.

Action: Provide a specialist menopause service in every NHS Board, and where sub-specialisation is impractical (e.g. Island Health Boards) develop a buddy system.

• There is a specialist menopause service in every mainland NHS Board. The specialist service aims to support healthcare professionals in primary care who are seeking further specialist menopause advice by phone and email, along with direct referrals for patients who met the referral criteria set out in Standard 11 of the British Menopause Society Practice Standards.
• An email-based buddy system is in place to support the Island NHS Boards. This facilitates access to a mainland NHS Board consultant who can provide specialist menopause advice.

Action: Develop a menopause and menstrual health workplace policy, as an example of best practice, starting with NHSScotland, and promote across the public, private and third sector

• The National Menopause and Menstrual Health Policy for NHSScotland and supporting documents were published on 31 October 2023. You can access the policy and supporting documents here.

As of 24 October 2024, the Menopause and Menstrual Health page on the National Wellbeing Hub, had been viewed 10,006 times by 7,362 users.

To inform the NHSScotland Menopause and Menstrual Health Policy, the working group who led the development worked in partnership with the University of Glasgow on ground-breaking research to establish a new evidence base on women’s experience of working in NHS Scotland in relation to menstrual health and menopause.

Since the launch of the policy a number of promotional actions have taken place including:

• A webinar hosted by the University of Glasgow for Survey Participants in November 2023.
• A webinar hosted by the University of Glasgow on ‘Menopause and Menstrual Health at Work: Changing the Conversation in March 2024.
• The Chartered Institute of Personnel and Development (CIPD) Scotland Annual Conference - World Cafe: Enabling women to thrive - supporting women’s health in the workplace in March 2024.
• The Holyrood Insight - Menopause in the Workplace in Scotland Conference on 26 March 2024.
• Article in April 2024 issue of the Economy stakeholder bulletin.
• Due to be included in the ‘Supporting Mentally Healthy Workplaces Employer Network’ newsletter.

Policy into Practice: Menopause and Menstrual Health in the Workplace

NHS Greater Glasgow and Clyde (NHSGGC): NHSGGC has a Staff Menopause and Menstrual Health Advisory and Implementation Group, which is multi-disciplinary and responsible for raising awareness of menopause information and resources, promotion of available training and ensuring support for staff and managers by implementing relevant policy and guidance.

There is also a Women’s Health section on their Staff Health and Wellbeing site which has information for staff and managers around menopause, including NHS Inform, the NHS Scotland policy and the supporting national wellbeing hub suite of resources.

The Staff Advisory Group have an action plan which includes:

• the promotion of the menopause policy and suite of resources
• creation of a Peer Support Menopause Hub to promote and share information and resources.

NHS Golden Jubilee (NHSGJ):

NHSGJ have taken forward a number of actions around menopause and menstrual health in the workplace, including the following:

• Established a Women’s Network and Menopause Cafés.
• Cognitive Behavioural Therapy (CBT) for those experiencing menopause.
• Internal communications on menopause and menstrual health related news and education.

NHS Grampian (NHSG)

NHSG have been proactive since the release of the Women’s Health Plan in August 2021. They set up a steering group in January 2022 to drive the project of a menopause-aware workforce forward.

This has included:

• Managers tool kit was developed and launched in June 2023 as a one stop tool to support all management and employees on what support is available to individuals – including OHS pathways, SSTS, local adjustments, alternative uniform guidance, education available, awareness posters. It was further updated following the launch of the national policy to include a hyperlink.
• A lead for menopause in the workplace was established in January 2022.

Action: Ensure women are properly supported around the time of menopause to assess their future risk of osteoporosis and fractures and given appropriate lifestyle advice.

• Information on the future risk of osteoporosis at the time of menopause has been included within the Women’s Health Platform on NHS Inform. This includes information on lifestyle changes like exercise and nutrition to improve bone health as well as advice on Hormone Replacement Therapy (HRT).
• The NHS Education for Scotland (NES) training resource on the menopause takes a life course approach, including ensuring healthcare professionals are able to support women in being aware of the risk of osteoporosis around the time of menopause – and what can help.

Action: Launch a public health campaign to remove stigma and raise awareness of the symptoms of menopause.

To highlight the symptoms of menopause, marketing activity took place throughout October 2024 across Scottish Government social media channels. This activity has included the creation of a short animation and poster to highlight less well-known symptoms, along with a series of short films with a clinician offering expert advice on managing symptoms. A stakeholder toolkit was created to share these materials with key partners, amplifying reach and complementing their own activity during Menopause Awareness Month. A webinar aimed at empowering women around menopause was also hosted in partnership with the ALLIANCE to mark World Menopause Day 2024.

In addition, work has taken place over the three years of the Plan to raise awareness of the menopause including the development of content on NHS Inform, including short films on what to expect from the peri menopause, menopause and mental health and menopause and sexual wellbeing.

Webinars have been held by the ALLIANCE to provide more information to women on menopause and resources developed including the Conversation Café toolkit to provide information to those who are not able to access information online.

Work to raise awareness of the symptoms of peri menopause, menopause and post menopause along with tackling stigma will continue beyond this phase of the plan.

Long Term Actions

Action: Build a basic understanding of menopause among all healthcare professionals. This should include awareness of the symptoms of perimenopause and menopause and awareness of intermediate and long-term consequences, and know where to signpost women for advice and support.

As a long term action, this work will continue beyond this phase of the Plan. Work to date includes:

• The NHS Education Scotland menopause educational resource, available on Turas learning in Autumn 2024, which will support healthcare professionals, particularly those working in General Practice and Primary Care, towards an improved standard of menopause care.
• The National Menopause Specialist Network continues to promote educational tools and opportunities such as the BMS GP guidance and training through their local networks; hosting local education sessions on the menopause; and sharing initiatives such as local drop-in sessions on menopause care.
• The Women’s Health Champion, in collaboration with cardiology and reproductive health colleagues, is leading work on the development of guidance and information for health care professionals on managing menopause in women with cardiovascular disease.

Wider work:

The GMC plan to introduce the Medical Licensing Assessment for all medical students graduating from UK universities from the academic year 2024-25 onwards. Within this assessment, there are several topics relating to women’s health, including menopause, obstetrics and gynaecology, to encourage a better understanding of women’s health among doctors as they start their careers in the UK.

Action: Acknowledge the importance of menopause, menstrual health and endometriosis within mental health policy, ensuring policies recognise the impact these conditions can have on women’s mental as well as physical health, including awareness of the symptoms of PMS and PMDD.

The Scottish Government worked closely with stakeholders, including the Equality and Human Rights Forum, to gather evidence and develop the Mental Health and Wellbeing Strategy and accompanying Delivery Plan. This evidence is published in the Scottish Government Mental Health Equality Evidence Report and highlights the impact menopause, menstrual health and other conditions can have on women’s mental health. The Strategy is informed by lived experience and underpinned by equality and human rights.

Core standards for mental health services and a national service specification for Psychological Therapies and Interventions have been published. The standards set out that the help someone receives should consider their cultural and social needs and be informed by what people say is important to them. This includes considering and being informed by any women’s health conditions such as menopause, menstrual health and endometriosis, as well as PMS and PMDD.

Civtech Menopause Challenge

In June 2023, the Scottish Government CivTech programme launched an innovation challenge to enhance access to menopause care for all women in Scotland.

The challenge is sponsored by CivTech and the Chief Scientist Office and is being delivered in collaboration with NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde and the West of Scotland Innovation Hub. The CivTech programme is focussed on innovation and collaboration. The products under development have been co-developed by the two participating companies alongside expert NHS clinicians and practitioners.

These are;

i) an app that will enable women to understand and self-manage symptoms using NHS and clinically approved guidelines and; ii) a digital therapeutic to help reduce the impact of some menopause symptoms.

As development continues, both products will undergo extensive user testing and evaluation with the intention of including NHS staff in the process. If all goes well, they will potentially be adopted by the NHS in Scotland however are currently still under development and subject to ongoing evaluation.